A nurse is caring for a client on the medical-surgical unit.

Exhibits

For each potential nursing action, click to specify if the 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.

Maintain water level at 2 cm.

Strip the tubing twice daily to ensure patency

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}

A.   Clamping the chest tube during ambulation can lead to increased intrathoracic pressure, which may cause tension pneumothorax or other complications. Chest tubes should remain unclamped to maintain proper drainage. However, it may be done briefly during tube changes or if there is a suspected air leak, always under specific medical orders.
B.   Burning pain in the chest could indicate complications such as infection or irritation at the insertion site. Reporting this symptom to the provider allows for timely assessment and intervention.
C.   A loose dressing around the chest tube can compromise the integrity of the system, leading to air leaks or contamination. Reinforcing the dressing helps maintain a sterile environment and prevents dislodgement of the tube.
D.   Maintaining the appropriate water seal level in the chest drainage system is essential for proper functioning. This prevents air from entering the pleural space while allowing drainage to occur effectively.
E.   Stripping or milking the chest tube is no longer a recommended practice as it can cause damage to the tissues and lead to airway obstruction or clot formation. Instead, gentle manipulation or rotation of the tubing may be done if there are signs of occlusion, but routine stripping is not recommended

Nursing Test Bank

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Correct Answer is C

Explanation

A. Cleaning a cat's litter box can expose pregnant individuals to toxoplasmosis, a risk factor for congenital birth defects.
B. Antibiotics are not effective against viral infections and should not be used unnecessarily.
C. Waiting until the chickenpox sores have crusted reduces the risk of transmission, indicating an understanding of infection prevention. This statement reflects appropriate knowledge about infectious disease control during pregnancy.
D. While handwashing is important, the recommended duration is at least 20 seconds, and hot water is not necessary for effective hand hygiene.

A. Pedal pulses B. Breath sounds C. Heart rate D. Movement of right foot E. Respiratory rate F. Pulse oximetry

Correct Answer is ["B","C","E","F"]

Explanation

A. While it's important to assess pedal pulses regularly, there is no indication in the scenario that the pedal pulses are abnormal or require immediate follow-up. The description mentions bilateral pedal pulses being present and intact throughout both days, suggesting no acute issues with peripheral circulation.

B. Crackles heard at the bases indicate possible pulmonary complications such as atelectasis or pneumonia, requiring further assessment and intervention.
C. A heart rate of 112/min indicates tachycardia, which could be a sign of pain, anxiety, or underlying cardiovascular issues. Further evaluation is needed to determine the cause.
D. The scenario states that the movement and sensation of the right foot are intact, with warm skin and no change in pigmentation. There are no signs of compromised neurovascular status in the right foot based on the provided information, so immediate follow-up for this finding is not necessary.
E. A respiratory rate of 28/min is elevated, suggesting respiratory distress or inadequate ventilation. Prompt assessment and intervention are necessary to address any respiratory issues.
F. A pulse oximetry reading of 88% on room air indicates hypoxemia, which requires immediate attention to ensure adequate oxygenation. Further assessment and intervention are needed to improve oxygen saturation levels.

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A nurse is caring for a client on the medical-surgical unit. Exhibits For each potential nursing action, click to specify if the action is indicated or contraindicated for the client who has a chest tube.

Nursing Test Bank

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Correct Answer is C

Explanation

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Explanation

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A nurse is caring for a client on the medical-surgical unit.

Exhibits

For each potential nursing action, click to specify if the action is indicated or contraindicated for the client who has a chest tube.