A nurse is caring for a client with a chest tube in place for treatment of a hemothorax. The nurse should prioritize which nursing intervention when caring for this client?
Empty the drainage from the pleuravac at the end of each shift.
Report serosanguinous drainage in the pleuravac.
Milk the chest tube every 4 hours to dislodge clotted blood.
Assist with coughing and deep breathing exercises every hour.
The Correct Answer is D
A. Empty the drainage from the pleuravac at the end of each shift: This is not a standard practice. Chest tube drainage systems typically have a built-in mechanism to handle drainage, and monitoring and recording the output is essential.
B. Report serosanguinous drainage in the pleuravac: Serosanguinous drainage (a mix of blood and serous fluid) can be expected in a hemothorax, especially initially. Reporting is necessary if there are significant changes in the amount or type of drainage.
C. Milk the chest tube every 4 hours to dislodge clotted blood: Milking or stripping the chest tube is generally not recommended as it can create high negative pressures that can damage lung tissue.
D. Assist with coughing and deep breathing exercises every hour: Encouraging coughing and deep breathing helps prevent atelectasis and promotes lung expansion, which is crucial for recovery from a hemothorax.
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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
The nurse should first place the client in high Fowler's position to ease the breathing and improve oxygenation, as the client is experiencing increased dyspnea and chest pain. This position allows for better lung expansion and can be a critical immediate intervention. Following this, the nurse should obtain IV access to facilitate the administration of medications and fluids as needed. IV access is essential for the rapid administration of potential treatments, including anticoagulants, which may be required if a pulmonary embolism is confirmed. These actions are prioritized to address the client's immediate respiratory distress and to prepare for further interventions based on the evolving clinical situation. It is important to note that each clinical scenario is unique, and the interventions should be tailored to the client's specific needs and the healthcare provider's clinical judgment.
Correct Answer is B
Explanation
A. Hamburger on a bun, banana: This choice is high in protein and potassium, which may not be suitable for someone with chronic renal disease, as excessive potassium intake can be harmful to individuals with impaired kidney function.
B. Carrots, green leafy vegetables, a pear: This choice is low in potassium and phosphorus, making it suitable for someone with chronic renal disease. Carrots and green leafy vegetables are generally lower in potassium, and a pear is a low-potassium fruit option.
C. Spaghetti with meat sauce, breadstick: This choice may be high in protein and sodium, depending on the sauce and breadstick ingredients, which may not be ideal for someone with chronic renal disease.
D. Cold cuts with bun, blueberries: Cold cuts can be high in sodium, and blueberries are moderately high in potassium, so this choice may not be appropriate for someone with chronic renal disease.
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