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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Health care providers should be told about the diagnosis to deliver safe care: Health care providers need to know the client's diagnosis to provide appropriate and safe care. This includes administering medications, assessing for opportunistic infections, and implementing preventive measures.
B. Most people in current society would be accepting of the diagnosis: While stigma surrounding HIV/AIDS has decreased over time, disclosure is a personal decision, and not all individuals may be accepting of the diagnosis. Therefore, this statement may not always be accurate.
C. Intimate partners should be told so they can protect themselves: Disclosing the diagnosis to intimate partners is essential for their health and well-being, as it allows them to take necessary precautions to prevent transmission of the virus.
D. The diagnosis is reportable to the state health department: In many jurisdictions, HIV/AIDS diagnoses are reportable to the state health department for surveillance and public health monitoring purposes. This reporting is typically done without disclosing the client's identity.
E. Secrecy about the diagnosis is the privilege of the client: While confidentiality is crucial, it's important to balance it with public health considerations and the well-being of others who may be at risk of infection.
Correct Answer is "{\"xRanges\":[104.2578125,134.2578125],\"yRanges\":[114.30078125,144.30078125]}"
Explanation
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