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 D
Explanation
Choice A reason: This is an important action, but not the first one. The nurse should first address the client's comfort and inflammation before teaching them how to use the eye drops.
Choice B reason:Option B (warm compresses)is a key intervention for blepharitis to improve meibomian gland function and reduce crusting. However, assessment (Option D) must precede treatment to ensure no contraindications (e.g., corneal abrasion) and tailor care appropriately.
Choice C reason: This is a helpful action, but not the first one. The nurse should first apply warm compresses to the affected eye, and then dim the lights to reduce the sensitivity and pain.
Choice D reason:Thefirst stepin the nursing process isassessment. Even with a diagnosis of blepharitis, the nurse mustinspect the eyesto evaluate the current severity, presence of drainage (e.g., purulent vs. serous), redness, or signs of secondary infection (e.g., bacterial involvement). This informs subsequent interventions.
Correct Answer is D
Explanation
Choice A reason: This is a normal finding, not an indication of breast cancer. Lumps that are mobile and tender upon palpation prior to a menstrual period are usually benign and related to hormonal changes.
Choice B reason: This is a normal finding, not an indication of breast cancer. Multiple round masses that are tender and found in both breasts are usually benign and related to fibrocystic breast changes.
Choice C reason: This is a normal finding, not an indication of breast cancer. Bilaterally darkened areolas are usually benign and related to genetic factors, pregnancy, or aging.
Choice D reason: This is an abnormal finding, and an indication of breast cancer. A nontender hard lump that is palpated in one breast is usually malignant and related to abnormal cell growth.
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