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.

Answer and Explanation

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 ["A","B","C","D"]

Explanation

A. Client has increased urine specific gravity: Increased urine specific gravity indicates concentrated urine, which is a hallmark of SIADH and should be reported as it reflects the excessive retention of water.

B. Changes in the client's behavior: Behavioral changes can be indicative of hyponatremia, a serious complication of SIADH, and should be reported immediately.

C. Client is complaining of nausea: Nausea is a symptom of hyponatremia, which is a common and dangerous consequence of SIADH that needs prompt attention.

D. Client is complaining of severe headache: A severe headache can also be a sign of hyponatremia and potential cerebral edema, both of which are critical conditions needing urgent intervention.

E. Client's urine output is only 50 cc/hr: While reduced urine output can be associated with SIADH, 50 cc/hr is not extremely low and might not be immediately alarming on its own. The other symptoms are more critical and should take precedence in reporting to the provider.

A. Manage the emotions. B. Breaking the ground rules. C. Disregard the conflict. D. Clarify the problem.

Correct Answer is D

Explanation

A. Manage the emotions: Managing emotions is an important aspect of conflict resolution, but it typically occurs after the problem has been clarified and during the negotiation process to promote constructive dialogue and prevent escalation of conflict.

B. Breaking the ground rules: Breaking the ground rules refers to violating established guidelines or principles for effective communication and negotiation. This step is not evident in the scenario described.

C. Disregard the conflict: Disregarding the conflict would involve ignoring or avoiding addressing the issues altogether, which is not an appropriate approach to conflict resolution. The scenario indicates that the nurse manager is actively engaged in addressing the conflict.
D. Clarify the problem: In negotiation, clarifying the problem involves identifying and defining the underlying issues or concerns contributing to the conflict. Creating a list of main issues helps ensure that all parties have a clear understanding of what needs to be addressed and provides a foundation for developing potential solutions.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is exhibiting manifestations of syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse report to the provider? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

The nurse manager is negotiating a conflict between the staff nurses and nursing assistants. The nurse manager talked to everyone involved and created a list of the main issues. Which step in the negotiation process does this best describe?

Correct Answer is D

Explanation

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