A nurse is caring for a patient with a chest tube connected to wall suction due to a right-sided pneumothorax. The patient reports a sensation of chest burning.
What should the nurse do next?
Clamp the patient’s chest tube.
Increase the patient’s wall suction.
Strip the patient’s chest tube.
Reposition the patient.
The Correct Answer is D
Choice A rationale
Clamping the patient’s chest tube is not the appropriate action. Clamping the tube can lead to tension pneumothorax, which is a life-threatening condition.
Choice B rationale
Increasing the patient’s wall suction is not the correct action. The sensation of chest burning is not related to the level of suction. Increasing the suction could potentially cause more harm.
Choice C rationale
Stripping the patient’s chest tube is not recommended. This action can cause negative pressure in the chest and can lead to injury of the lung tissue.
Choice D rationale
Repositioning the patient is the correct action. The sensation of chest burning could be due to the position of the chest tube. Repositioning the patient may alleviate the discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Negligence refers to conduct that falls below the standard established by law for the protection of others against unreasonable risk of harm. A nurse leaving her shift early without notifying the charge nurse could be considered negligent if it results in harm to a patient.
Choice B rationale
Battery refers to the intentional and offensive or harmful touching of another person without their consent. This does not apply to the scenario provided.
Choice C rationale
Slander involves making false spoken statements that damage a person’s reputation. This does not apply to the scenario provided.
Choice D rationale
Libel involves making false written statements that damage a person’s reputation. This does not apply to the scenario provided.
Correct Answer is C
Explanation
Choice A rationale
Performing passive range of motion exercises on the right leg in Buck’s traction may not be appropriate. These exercises involve moving the joint without the patient’s muscles doing the work, which could disrupt the traction.
Choice B rationale
Isometric exercises involve contracting the muscles without moving the joints. While these exercises can be beneficial for maintaining muscle strength, they may not promote mobility.
Choice C rationale
Performing active range-of-motion exercises on the left leg can help promote mobility. These exercises involve the patient moving the joint through its full range of motion, which can help maintain joint flexibility and muscle strength.
Choice D rationale
Log rolling the patient every 2 hours may not be appropriate for a patient in Buck’s traction. This technique involves turning the patient as a unit to prevent twisting and protect the spine, which could disrupt the traction.
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