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. Skin rash with fever

Stevens-Johnson syndrome (SJS) is a severe and potentially life-threatening hypersensitivity reaction that can occur as a rare side effect of certain medications, including allopurinol.

Monitoring and early recognition of SJS symptoms are crucial for prompt medical.

Skin rash with fever is a hallmark manifestation of Stevens-Johnson syndrome. It often starts with flu-like symptoms such as fever and malaise, followed by the appearance of a widespread, painful, and rapidly progressing rash. The rash typically involves the mucous membranes, including the mouth, nose, and eyes, and can be accompanied by blisters or sores. Prompt reporting of these symptoms is critical for early diagnosis and intervention.

Tinnitus with ear pain in (option A) is incorrect because it is not typically associated with Stevens- Johnson syndrome. It may indicate another condition or side effect unrelated to SJS.

Hyperreflexia, which refers to abnormally increased reflexes, in (option B) is incorrect because it is not a characteristic manifestation of Stevens-Johnson syndrome. It may indicate a neurological condition or reaction to another medication, but it is not specific to SJS.

Diplopia, or double vision, in option (D) is incorrect because it is not commonly associated with Stevens- Johnson syndrome. It may be caused by other ocular or neurological conditions.

In summary, the nurse should instruct the client taking allopurinol to monitor and report the manifestation of a skin rash with fever. This is important because it may indicate the development of Stevens-Johnson syndrome, a severe and potentially life-threatening reaction to the medication. Early recognition and medical intervention are crucial to minimize complications and ensure appropriate treatment.

A. Thyroid stimulating hormone. B. Blood urea nitrogen C. Prothrombin time D. Arterial blood gases

Correct Answer is A

Explanation

Levothyroxine is a medication used to treat hypothyroidism, and monitoring the TSH levels helps determine the effectiveness of the medication.

Blood urea nitrogen (BUN) is a test used to assess kidney function and is not specifically related to thyroid function or levothyroxine therapy.

Prothrombin time (PT) is a test used to evaluate the clotting ability of the blood and is not directly related to thyroid function or levothyroxine therapy.

Arterial blood gases (ABGs) are used to assess oxygen and carbon dioxide levels in the blood and evaluate acid-base balance. ABGs are not specifically related to thyroid function or levothyroxine therapy.

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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

A nurse is reinforcing teaching with a client who is taking allopurinol about the risk for developing Stevens-Johnson syndrome. For which of the following manifestations should the nurse instruct the client to monitor and report?

Correct Answer is C

Explanation

A nurse is caring for a client who has a prescription for levothyroxine. Which of the following laboratory tests should the nurse monitor?

Correct Answer is A

Explanation

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