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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Assigning the UAP to provide care for another client and assume full care of the client is not an action that the nurse should take, as this is unnecessary and inefficient. The UAP can safely assist the client with influenza if they follow proper infection control measures. This is an incorrect choice.
Choice B reason: Reviewing the need for the UAP to wear a face mask while in close contact with the client is an action that the nurse should take, as this can protect the UAP and others from droplet transmission of influenza. This is a standard precaution that should be reinforced by the nurse. Therefore, this is the correct choice.
Choice C reason: Instructing the UAP to apply a fitted respirator mask before entering the client's room is not an action that the nurse should take, as this is not indicated for a client with influenza. A respirator mask is required for airborne transmission, not droplet transmission. This is another incorrect choice.
Choice D reason: Directing the UAP to notify the nurse of any changes in the client's respiratory status is not an action that the nurse should take, as this is a general instruction that does not address the specific issue of infection control. This is another incorrect choice.
Correct Answer is ["1"]
Explanation
To calculate how many mL/hr the nurse should program the infusion pump, we need to use the following formula:
mL/hr = (units/hr) / (units/mL)
where units/hr is the prescribed dose of insulin per hour, and units/mL is the concentration of insulin in the IV solution.
In this case, we are given that:
units/hr = 1 unit (the usual starting dose for IV insulin)
units/mL = 100 units / 100 mL = 1 unit/mL
Plugging these values into the formula, we get:
mL/hr = (1 unit/hr) / (1 unit/mL)
mL/hr = 1 mL/hr
Therefore, the nurse should program the infusion pump to deliver 1 mL/hr.
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