A nurse is caring for a client who is to have his chest tube removed. Which of the following actions should the nurse take?
Cover the insertion site with a hydrocolloid dressing.
Provide pain medication immediately after removal.
Auscultate the lungs after removal.
Delegate removal of the chest tube to an assistive personnel (AP).
The Correct Answer is C
Choice A reason: This is an incorrect action, because covering the insertion site with a hydrocolloid dressing can prevent air from escaping and cause a subcutaneous emphysema, which is a complication of chest tube removal. The insertion site should be covered with a sterile gauze dressing and taped on three sides.
Choice B reason: This is an important action, but not the first one. The nurse should provide pain medication before removal, not immediately after, to reduce the discomfort and anxiety of the client.
Choice C reason: This is the correct action, because auscultating the lungs after removal can help assess the respiratory status and detect any signs of pneumothorax, such as diminished or absent breath sounds.
Choice D reason: This is an incorrect action, because delegating removal of the chest tube to an AP is beyond the scope of practice and can cause harm to the client. The removal of the chest tube should be performed by the nurse or the provider.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is an important action, but not the first one. The nurse should obtain the prescribed irrigation solution after assessing the client's pain level and providing analgesia if needed.
Choice B reason: This is an important action, but not the first one. The nurse should don personal protective equipment after assessing the client's pain level and providing analgesia if needed.
Choice C reason: This is the correct action, because checking the client's pain level is the first step in the wound care process. The nurse should assess the client's pain level using a valid and reliable pain scale, and administer analgesia as prescribed before irrigating the wound.
Choice D reason: This is an important action, but not the first one. The nurse should place a waterproof pad under the client's extremity after assessing the client's pain level and providing analgesia if needed.
Correct Answer is B
Explanation
Choice A reason: This is an incorrect instruction, because it is not necessary to take this medication for the rest of your life to prevent recurrence. Isoniazid is usually taken for 6 to 9 months, or as prescribed by the provider, to treat active TB or latent TB infection.
Choice B reason: This is the correct instruction, because your provider will monitor your liver function while you are taking this medication. Isoniazid can cause hepatotoxicity, which is a serious side effect that can damage the liver and cause jaundice, nausea, vomiting, or abdominal pain.
Choice C reason: This is an incorrect instruction, because you should avoid alcohol intake while you are taking this medication. Alcohol can increase the risk of hepatotoxicity and interfere with the metabolism of isoniazid.
Choice D reason: This is an incorrect instruction, because it is not recommended to take this medication with a meal to increase absorption. Isoniazid should be taken on an empty stomach, at least 1 hour before or 2 hours after a meal, to ensure optimal absorption and effectiveness.
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