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.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A reason: This is correct because it addresses both the physical and emotional needs of the child and the mother. The nurse should provide comfort and reassurance to the mother and explain that occasional accidents are normal and not a sign of failure.

Choice B reason: This is incorrect because it implies that the mother is incompetent and needs external help. The nurse should first establish rapport and trust with the mother before suggesting any resources or interventions.

Choice C reason: This is incorrect because it suggests that there is something wrong with the child's kidneys, which may alarm and offend the mother. The nurse should not jump to conclusions without assessing the child's history and symptoms.

Choice D reason: This is incorrect because it generalizes and stereotypes boys as being slower than girls in toilet training. The nurse should not make assumptions based on gender and should respect individual differences.

A. Ensure that the infant's crib mattress is firm. B. Prop the infant with a pillow when in a side-lying position. C. Swaddle the infant in a blanket for sleeping. D. Place the infant in a prone position whenever possible.

Correct Answer is A

Explanation

Choice A reason: This is correct because a firm mattress reduces the risk of suffocation and rebreathing of carbon dioxide, which are associated with SIDS.

Choice B reason: This is incorrect because propping the infant with a pillow can cause the infant to slide down and suffocate or obstruct the airway.

Choice C reason: This is incorrect because swaddling the infant in a blanket can cause overheating, which is a risk factor for SIDS.

Choice D reason: This is incorrect because placing the infant in a prone position can increase the risk of SIDS by impairing gas exchange and thermoregulation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse on a pediatric unit observes a distraught mother in the hallway scolding her 3-year-old son for wetting his pants. What initial action should the nurse take?

Correct Answer is A

Explanation

The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include?

Correct Answer is A

Explanation

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