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 B reason: the client with antisocial behavior is at risk of being harmed by other clients or harming others. The nurse should intervene immediately to prevent violence and ensure safety.
Choice A reason: the client with anorexia nervosa who is refusing to eat the evening snack is not in immediate danger. The nurse should monitor the client's nutritional status and weight, but this can be done later.
Choice C reason: the client with bipolar disorder who is pacing around the lobby is not in immediate danger. The nurse should assess the client's mood and energy level, but this can be done later.
Choice D reason: the client with major depression who refuses to participate in group is not in immediate danger. The nurse should encourage the client to join the group, but this can be done later.
Correct Answer is D
Explanation
Choice D reason: frequent exposure to sunlight is the most significant environmental factor when planning care for a client with osteomalacia. Osteomalacia is a condition in which the bones become soft and weak due to inadequate mineralization, often caused by vitamin D deficiency. Vitamin D is essential for calcium absorption and bone health, and it can be synthesized by the skin when exposed to sunlight. The nurse should encourage the client to get at least 15 minutes of sunlight per day or take vitamin D supplements as prescribed.
Choice A reason: quiet, calm surroundings are not a specific environmental factor for a client with osteomalacia. Quiet, calm surroundings may help reduce stress and promote relaxation, but they do not affect bone mineralization or vitamin D synthesis.
Choice B reason: stimulating sounds and activity are not a specific environmental factor for a client with osteomalacia. Stimulating sounds and activity may help improve mood and cognition, but they do not affect bone mineralization or vitamin D synthesis.
Choice C reason: cool, moist air is not a specific environmental factor for a client with osteomalacia. Cool, moist air may help relieve respiratory symptoms or allergies, but it does not affect bone mineralization or vitamin D synthesis.
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