A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?

Ensure the device is kept below the level of the client's chest.

Clamp the chest tube every 4 hr.

Place the client in a supine position.

Empty the collection chamber every 8 hr.

Answer and Explanation

The Correct Answer is A

Ensuring the device is kept below the level of the client's chest is important to ensure that the drainage system functions properly by allowing the fluid and air to flow downhill. Placing the device below the level of the chest helps facilitate gravity drainage.

Continuous suction is required for proper functioning of the chest tube drainage system. Clamping the chest tube can disrupt the suction and impede the removal of air or fluid from the pleural space. Only in specific circumstances, such as when changing the drainage system or assessing for air leaks, may the healthcare provider request a temporary clamping of the chest tube.

Positioning the client semi-Fowler's, with the head of the bed elevated, can help promote lung expansion and improve oxygenation. The specific positioning may vary depending on the client's condition and the healthcare provider's recommendations.

The nurse should empty the collection chamber as per the facility's protocol, which typically includes monitoring the drainage and emptying it when it reaches a certain level. Regular emptying of the collection chamber helps maintain proper functioning of the chest tube system and allows for accurate measurement of drainage output.

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Correct Answer is C

Explanation

Explanation

C. Position the client on their left side

The symptoms of feeling dizzy, racing heart, and becoming pale while lying on their back are consistent with supine hypotensive syndrome or vena cava syndrome. This condition occurs when the pregnant uterus compresses the vena cava, reducing blood flow back to the heart and causing a drop-in blood pressure.

Positioning the client on their left side helps alleviate the pressure on the vena cava, allowing for improved blood flow and preventing further symptoms. This position optimizes blood circulation and reduces the risk of complications. The nurse should assist the client in turning onto their left side and ensure they are comfortable.

Providing the client with a glass of orange juice (option A) is not recommended as it may be helpful in cases of low blood sugar or hypoglycemia, but it is not the most appropriate action in this scenario.

Instructing the client to take a brisk walk (option B) is not recommended since physical exertion can further worsen the symptoms and increase the risk of complications.

Checking the client's temperature (option D) is not necessary as the reported symptoms are not indicative of a fever or infection.

Therefore, the most appropriate action for the nurse to take in this situation is to position the client on their left side (option C).

A. Nervousness B. Pruritus C. Cough D. Polyuria

Correct Answer is A

Explanation

Explanation

A, Nervousness

Levothyroxine is a medication used to treat hypothyroidism, a condition in which the thyroid gland does not produce enough thyroid hormones. Thyrotoxicosis, on the other hand, is a condition characterized by an excess of thyroid hormones in the body, which can occur as a side effect of levothyroxine or other thyroid medications.

Nervousness is a common symptom of thyrotoxicosis. Excess thyroid hormones can lead to increased sympathetic nervous system activity, causing symptoms like nervousness, restlessness, anxiety, and palpitations.

Pruritus (itching) in (option B) is not correct because it is not a typical manifestation of thyrotoxicosis. Itching is not directly related to thyroid hormone levels and is more likely to be associated with other conditions or medication side effects.

Cough In (option C) is not correct because it is not a typical manifestation of thyrotoxicosis. Coughing is not a symptom directly related to thyroid hormone levels and is more likely to be associated with respiratory or other conditions.

Polyuria (increased urination) in (option D) is not correct because it is not a typical manifestation of thyrotoxicosis. Polyuria is not a symptom directly related to thyroid hormone levels and is more likely to be associated with other conditions, such as diabetes or kidney problems.

If the client experiences symptoms of thyrotoxicosis, such as nervousness, palpitations, or any other concerning signs, it is essential to notify the healthcare provider promptly. The provider may need to adjust the dosage of levothyroxine or consider other treatment options to address the excess thyroid hormone levels and ensure the client's well-been

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A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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