A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take?
Secure chest tube to the stretcher for transport.
Administer PRN pain medication prior to transport.
Mark the amount of chest drainage on the container.
Keep chest tube container below the site of insertion.
The Correct Answer is D
Choice A reason: Securing chest tube to the stretcher for transport is a good practice, but it is not the most important action. The chest tube should be secured to prevent accidental dislodgement or kinking, but it does not affect the function of the chest tube or the drainage system.
Choice B reason: Administering PRN pain medication prior to transport is a compassionate action, but it is not the most important action. The client may experience pain due to the chest tube, the intubation, or the underlying condition, but pain relief is not a priority over maintaining adequate ventilation and drainage.
Choice C reason: Marking the amount of chest drainage on the container is a useful action, but it is not the most important action. The amount of chest drainage should be recorded and reported to monitor the client's status and detect any complications, such as hemorrhage or infection, but it does not affect the immediate function of the chest tube or the drainage system.
Choice D reason: Keeping chest tube container below the site of insertion is the most important action for the nurse to take. The chest tube container should be kept below the level of the client's chest to maintain a gravity-dependent pressure gradient that allows air and fluid to drain from the pleural space. If the container is raised above the site of insertion, it can cause backflow of air or fluid into the pleural space, which can compromise ventilation and cause tension pneumothorax.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Marking an outline of the "olive-shaped" mass in the right epigastric area is not a priority nursing action. The mass is caused by hypertrophy of the pyloric sphincter, which obstructs gastric emptying and causes projectile vomiting. The mass may not be palpable in all cases.
Choice B reason: This is the correct answer because maintaining a continuous infusion of IV fluids per prescription is essential to prevent dehydration and electrolyte imbalance in the infant. The infant may have significant fluid loss due to vomiting and poor intake.
Choice C reason: Monitoring amount of intake and infant's response to feedings is important, but not the highest priority. The infant may have difficulty feeding due to nausea, vomiting, and abdominal pain.
Choice D reason: Instructing parents regarding care of the incisional area is a post-operative nursing action, not a pre-operative one. The parents will need to learn how to keep the incision clean and dry, monitor for signs of infection, and administer pain medication as prescribed.
Correct Answer is ["B","D","E"]
Explanation
Choice A reason: Providing diet low in phosphorus is not a relevant intervention for a client with cirrhosis of the liver. Phosphorus is a mineral that helps maintain bone health and acid-base balance. Cirrhosis of the liver does not affect phosphorus levels, but it can cause low calcium levels due to impaired vitamin D metabolism. The nurse should provide a diet high in calcium and vitamin D to prevent osteoporosis and fractures.
Choice B reason: This is a correct answer because noting signs of swelling and edema is an important intervention for a client with cirrhosis of the liver. Cirrhosis of the liver is a chronic condition that causes scarring and damage to the liver tissue, impairing its function and blood flow. This can lead to portal hypertension, which is increased pressure in the portal vein that carries blood from the digestive organs to the liver. Portal hypertension can cause fluid accumulation in the abdomen (ascites) and legs (peripheral edema). The nurse should assess the client's weight, fluid intake and output, abdominal girth, and extremity circumference.
Choice C reason: Increasing oral fluid intake to 1,500 mL daily is not a suitable intervention for a client with cirrhosis of the liver. Fluid intake should be individualized based on the client's fluid status, electrolyte levels, and urine output. Increasing fluid intake may worsen fluid retention and electrolyte imbalance in clients with cirrhosis of the liver. The nurse should restrict fluid intake to 1,000 to 1,500 mL daily or as prescribed by the healthcare provider.
Choice D reason: This is a correct answer because monitoring abdominal girth is an essential intervention for a client with cirrhosis of the liver. Abdominal girth is a measurement of the circumference of the abdomen at the level of the umbilicus. It reflects the amount of fluid in the peritoneal cavity, which can increase due to portal hypertension and hypoalbuminemia in clients with cirrhosis of the liver. The nurse should measure and record abdominal girth daily or more frequently as indicated.
Choice E reason: This is a correct answer because reporting serum albumin and globulin levels is a significant intervention for a client with cirrhosis of the liver. Albumin and globulin are types of proteins that are synthesized by the liver and have various functions in the body, such as maintaining fluid balance, transporting hormones and drugs, and fighting infections. Cirrhosis of the liver can cause low albumin levels due to reduced synthesis and increased loss through ascites or urine. Low albumin levels can cause edema, malnutrition, and increased risk of infection. Cirrhosis of the liver can also cause high globulin levels due to chronic inflammation or immune response. High globulin levels can indicate autoimmune diseases, infections, or malignancies. The nurse should monitor and report serum albumin and globulin levels as they reflect liver function and overall health status.
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