A nurse is assisting in the care of a client.
Admission Assessment.
1500: Client transferred from postanesthesia care unit, following a left lung lobectomy.
Client alert and oriented to person, place, time,. and situation.
Reports pain as 3 on a scale of 0 to 10. Dressing dry and intact to left chest.
Water seal chest tube drainage system has 100 mL sanguineous drainage.
Right lung sounds clear.
Left lung sounds diminished.
For each potential nursing action, click to specify if the potential action is. indicated or contraindicated for the client who has a chest tube.
Clamp chest tube when client ambulates.
Report burning pain in chest to provider.
Reinforce dressing around the tube as needed if it loosens.
Strip the tubing twice daily to ensure patency.
Maintain chest tube below the chest.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}
Clamp chest tube when client ambulates. Contraindicated. Clamping the chest tube can cause a tension pneumothorax, which is a life-threatening condition. The chest tube should be kept open and patent at all times, unless ordered by the provider for a specific reason. Report burning pain in chest to provider. Indicated.
Burning pain in the chest may indicate an infection, inflammation, or injury to the pleura or lung tissue. The provider should be notified of any changes in the client’s pain or discomfort.
Reinforce dressing around the tube as needed if it loosens. Indicated. The dressing around the chest tube should be kept dry and intact to prevent air leaks and infection. If the dressing becomes loose, wet, or soiled, it should be reinforced with sterile gauze and tape.
Strip the tubing twice daily to ensure patency. Contraindicated. Stripping or milking the tubing can cause increased negative pressure in the chest cavity, which can damage the lung tissue and impair gas exchange. The tubing should be assessed for kinks, clots, or obstructions, and gently tapped or repositioned if needed.
Maintain chest tube below the chest. Indicated. The chest tube should be kept below the level of the chest to facilitate drainage by gravity and prevent backflow of fluid into the pleural space.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Limiting the use of familiar objects is not recommended for clients with Alzheimer's disease. Familiar objects can provide comfort and security to these clients and help them maintain a sense of familiarity in their environment.
Choice B rationale:
Making a schedule of daily tasks is a helpful intervention for clients with Alzheimer's disease. Routine and structure can reduce frustration and anxiety in clients with cognitive impairment by providing predictability and a sense of purpose.
Choice C rationale:
Having several family members visit daily may be overwhelming for the client with Alzheimer's disease, leading to increased confusion and agitation. It is essential to balance social interaction with the client's comfort level and needs.
Choice D rationale:
Asking questions that require more than one answer can be confusing for clients with Alzheimer's disease. s should be simple and straightforward to enhance understanding and communication.
Correct Answer is B
Explanation
Choice A rationale:
"Request an x-ray of the preschooler's neck." - This action is not indicated for a preschooler with manifestations of respiratory syncytial virus (RSV) RSV primarily affects the respiratory system, and an x-ray of the neck would not be relevant for this condition.
Choice B rationale:
"Initiate droplet precautions." - This is the correct answer. RSV is highly contagious and primarily spreads through respiratory droplets. Initiating droplet precautions, such as wearing a mask and practicing proper hand hygiene, is essential to prevent the transmission of the virus to others in the healthcare setting.
Choice C rationale:
"Administer fluconazole to the preschooler." - Fluconazole is an antifungal medication and would not be appropriate for treating RSV, which is a viral respiratory infection. Antifungal medications are used to treat fungal infections, not viral ones.
Choice D rationale:
"Monitor the preschooler's urine for protein." - Monitoring urine for protein is not relevant to the care of a preschooler with RSV. This action is more suitable for conditions that may affect the kidneys or urinary system but not RSV, which primarily affects the respiratory system.
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