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
Peer-reviewed journal articles undergo a rigorous review process by experts in the field before being published. This process ensures that the information presented is based on sound research methods, accurate data, and relevant evidence. Journal articles are considered reliable sources of information as they are reviewed by experts in the field, and the research findings can contribute to evidence-based practice.
First-hand experience with wound care products: While personal experience can be valuable, it may not always reflect the most up-to-date or evidence-based practices. Individual experiences can be subjective and may not have been subject to rigorous evaluation or research.
Information from a wound care product vendor: Information from a vendor may be biased and focused on promoting their own products. It is important to critically evaluate the information and consider whether it is supported by evidence and aligns with current best practices.
An entry on a nursing blog addressing wound healing: Blog entries can vary in quality and credibility. Not all blogs are written or reviewed by experts, and the information provided may not always be evidence-based or reliable. It is important to critically assess the source, author's qualifications, and references cited in the blog post.
Correct Answer is A
Explanation
Choice A rationale:
Colostrum, the initial breast milk produced after childbirth, is crucial for a newborn's health because it contains a high concentration of antibodies, also known as immunoglobulins (IgA), which provide passive immunity to the baby. These antibodies are essential because a newborn's immune system is immature and not yet capable of producing its antibodies. IgA antibodies in colostrum help protect the baby against various infections, including respiratory and gastrointestinal illnesses. Therefore, choice A is the correct answer as it accurately reflects the importance of colostrum in providing immune protection for the newborn.
Choice B rationale:
Colostrum does not primarily provide vitamin K. While vitamin K is essential for newborns to prevent bleeding disorders, it is not the primary function of colostrum. Colostrum's primary role is to provide immune protection.
Choice C rationale:
Colostrum does contain trace amounts of iron, but its iron content is not the primary reason for its importance. Iron stores in a newborn's body are typically established during the third trimester of pregnancy, and colostrum is not a significant source of iron for the baby. The primary role of colostrum is to provide antibodies, not iron.
Choice D rationale:
Colostrum does not contain a natural diuretic. Its purpose is not to stimulate the newborn to void. Instead, it focuses on providing immune protection and essential nutrients for the baby's initial growth and development.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.