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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. "I can take antacids at the same time as this medication.” This is generally incorrect. While antacids can provide quick relief, they can interfere with the absorption of pantoprazole. It's usually recommended to separate antacid use from pantoprazole by at least a couple of hours.
B. "I will need to remain upright for 1 hour after taking the medication.” This is incorrect. This is a common instruction for general GERD management, but not specifically related to taking the pantoprazole medication itself.
C. "I have to take this medication on an empty stomach.” This is generally correct. PPIs like pantoprazole work best when taken before meals, typically 30-60 minutes before breakfast. This allows the medication to be absorbed and ready to reduce acid production when you eat.
D. "I should expect to have diarrhea while taking this medication.” While diarrhea can be a side effect of pantoprazole, it's not a guaranteed or expected outcome.

A. "What would your family do without you?” B. "When you get better you will not feel this way.” C. "Why would you think a thing like that?” D. "Are you thinking of hurting yourself?”

Correct Answer is D

Explanation

Choice A rationale:

Asking, "What would your family do without you?" can be seen as judgmental and may not encourage open communication. It doesn't directly address the client's statement about feeling like a burden or wanting to be gone.

Choice B rationale:

Saying, "When you get better you will not feel this way," minimizes the client's feelings and can be invalidating. It does not show empathy or concern for the client's current emotional state.

Choice C rationale:

Asking, "Why would you think a thing like that?" can come across as judgmental and may make the client defensive. It does not directly address the client's emotional distress or suicidal ideation.

Choice D rationale:

This is the correct answer. "Are you thinking of hurting yourself?" is a direct and appropriate question to assess the client's risk of self-harm or suicide. It demonstrates concern for the client's well-being and opens the door for a more in-depth conversation about their feelings and thoughts. Assessing for suicidal ideation is a crucial step in providing appropriate care for a client with depressive disorder.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has GERD and a prescription for pantoprazole. Which of the following statements indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who has depressive disorder.The client states, "Everyone would be better off if I were not around." Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is assisting with planning an in-service for staff members about active shooter protocols.Which of the following information should the nurse recommend including?

A charge nurse is discussing confidentiality requirements with a newly licensed nurse when sharing a client's medical information.Which of the following individuals should the charge nurse identify as appropriate with whom to share client information?

A nurse is caring for a client who has AIDS.Which of the following solutions should the nurse use to disinfect the client's overbed table following a blood spill?

A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease.The client becomes agitated and combative when the nurse approaches him.Which of the following actions should the nurse plan to take?

The practical nurse (PN) is providing instructions to the unlicensed assistive personnel (UAP) preparing to give a total bed bath to an immobile client who has a continuous feeding via gastrostomy tube (GT). Which instruction is most important for the PN to emphasize?

A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?

A nurse is receiving change-of-shift report on four clients.Which of the following clients should the nurse plan to see first?

A nurse is implementing a bladder training program for a client who had a stroke.Which of the following interventions should the nurse take first?