A nurse is caring for a client who has a newly inserted chest tube. The nurse should clarify which of the following prescriptions with the provider?
Vigorously strip the chest tube twice daily.
Assist the client out of bed three times daily.
Notify the provider when tiddling ceases.
Administer morphine 2 mg IV bolus every 3 hr. PRN for pain.
The Correct Answer is A
Choice A Reason:
Vigorously strip the chest tube twice daily. The nurse should clarify the prescription to "vigorously strip the chest tube twice daily" with the provider. Stripping or milking a chest tube is generally not recommended, as it can cause damage to the tube and lead to complications. The movement of fluid and air in the chest tube should be allowed to occur naturally based on the patient's own respiratory effort.
Choice B Reason:
Assist the client out of bed three times daily - This is a reasonable activity for a client with a chest tube, as mobility and deep breathing can help prevent complications.
Choice C Reason:
Notify the provider when tiddling ceases - Monitoring for tiddling (fluctuations in the water seal chamber with respiration) and notifying the provider when tiddling stops is important, as it might indicate a potential issue with the chest tube placement or functioning.
Choice D Reason:
Administer morphine 2 mg IV bolus every 3 hr PRN for pain - Administering pain relief for the client is appropriate and helps manage their comfort. Pain control is important to encourage deep breathing and prevent complications related to shallow breathing due to pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
A raised lesion with a rolled border - This description might be more indicative of basal cell carcinoma, a different type of skin cancer.
Choice B Reason:
An irregular lesion with irregular borders. Melanoma is a type of skin cancer that originates from melanocytes, the cells responsible for producing the pigment melanin. One of the key characteristics of melanoma is the presence of an irregularly shaped lesion with irregular borders. Melanomas often have uneven, jagged, or notched edges that distinguish them from benign moles or lesions.
Choice C Reason:
A reddened lesion with dilated blood vessels - This description might be more indicative of a vascular lesion or hemangioma, which is not a melanoma.
Choice D Reason:
A scaly lesion with a crusted appearance - This description might be more indicative of squamous cell carcinoma, another type of skin cancer.
Correct Answer is C
Explanation
Choice A Reason:
COPD (Chronic Obstructive Pulmonary Disease) - While COPD might influence the choice of anaesthesia and perioperative management, it is not a direct contraindication to heparin.
Choice B Reason:
Thalassemia - Thalassemia is a genetic blood disorder that affects haemoglobin production and the structure of red blood cells. It does not directly impact the ability to receive heparin.
Choice C Reason:
Thrombocytopenia. Thrombocytopenia, which is a low platelet count, is a contraindication to receiving heparin, an anticoagulant. Heparin works by preventing the formation of blood clots, but if a person has a low platelet count, their ability to form blood clots is already compromised. Administering heparin in this situation could increase the risk of bleeding and further reduce platelet count.
Choice D Reason:
Rheumatoid arthritis - Rheumatoid arthritis is an autoimmune condition affecting joints. It is not a contraindication to heparin use, but the client's overall health and medications should be considered when planning surgery and anticoagulant therapy.
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