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 B
Explanation
Step 1 is… The provider has prescribed 40 mg of fluoxetine to be taken orally daily.
Step 2 is… The available medication is fluoxetine 20 mg/mL. Therefore, the nurse should administer 40 mg ÷ 20 mg/mL = 2 mL89.
Correct Answer is A
Explanation
Choice A rationale
The statement “Our car seat is an infant model and is anchored in the car” indicates a correct understanding of car seat safety. Infant car seats are specifically designed to protect infants during a collision. They are rear-facing seats, which is the safest position for an infant because it provides the most support for the infant’s head, neck, and spine. Anchoring the car seat in the car is crucial as it ensures the seat stays in place during a collision.
Choice B rationale
The statement “The car seat is rear-facing in the front passenger seat” is incorrect. It is not safe to place a rear-facing car seat in the front passenger seat of a vehicle. In the event of a collision, an airbag can deploy and hit the car seat, causing serious injury to the infant.
Choice C rationale
The statement “I can fit my hand between the baby and the car seat harness” is incorrect. The harness of a car seat should be snug against the baby’s body. If you can fit your hand between the baby and the harness, it means the harness is too loose, which can be dangerous in the event of a collision.
Choice D rationale
The statement “Our car seat is front-facing in the back seat” is incorrect. Infants should always be in a rear-facing car seat until they reach the highest weight or height allowed by their car safety seat’s manufacturer.
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