The drainage in the chest tube of a client with emphysema has changed from viscous green to clear watery fluid. Which action is best for the nurse to tak?

Schedule a portable chest x-ray per PRN protocol.

Maintain the current IV antibiotic schedule.

Obtain a specimen of the drainage for culture.

"Milk" the tube to remove any clots.

Answer and Explanation

The Correct Answer is C

A.   A chest x-ray can be useful to assess for complications or changes in lung status, such as pneumothorax, pleural effusion, or changes in lung volume. However, the change in drainage color from viscous green to clear watery fluid may not immediately warrant an x-ray unless there are additional clinical concerns or symptoms suggesting a need for imaging.
B.   Continuing the IV antibiotic schedule is important if there is an ongoing infection that needs treatment. However, if the change in drainage is significant and suggests a potential change in the underlying condition or complication, it’s important to evaluate the cause of the change rather than solely relying on antibiotics.
C.   Obtaining a specimen of the drainage for culture is a valuable action if there is concern about infection or if the drainage characteristics have changed unexpectedly. Clear, watery fluid could indicate the presence of serous fluid or a change in the nature of the drainage, potentially due to infection or resolution of an infection.
D.   “Milking” or stripping the chest tube is not recommended as a routine practice because it can create negative pressure and potentially damage the pleural tissues or exacerbate issues. Additionally, the change in the drainage from viscous green to clear watery fluid does not necessarily indicate that clots are present or that tube milking would be helpful.

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Correct Answer is ["B","C","E"]

Explanation

A. This is important to prevent injury but is not the priority at this time.
B. This is important for monitoring the seizure progression and for providing information to the healthcare provider. However, it should be done while simultaneously performing the more critical interventions of ventilation and oxygenation.
C. This is the highest priority as the client is experiencing respiratory failure with a respiratory rate of 4 breaths/minute. Providing artificial ventilation is crucial to oxygenate the patient.
D. This is not necessary at this point and may not be feasible during the emergency situation.
E. While not as immediate as BVM ventilation, increasing oxygen delivery is essential to improve oxygenation levels.
F. Begin chest compressions: Chest compressions are indicated for cardiac arrest, not respiratory failure.

A. Minimize intake of spicy foods. B. Remain upright following meals. C. Avoid wearing tight fitting clothes. D. Begin a smoking cessation program.

Correct Answer is B

Explanation

A. Spicy foods can exacerbate GERD symptoms by irritating the esophagus and increasing acid production. While minimizing spicy foods is important, it is one of several dietary changes that can help manage GERD. It’s beneficial but may not be the single most critical instruction compared to other lifestyle modifications.
B. Remaining upright after meals is crucial for managing GERD. Lying down or reclining too soon after eating can allow stomach acid to flow back into the esophagus, worsening symptoms. Staying upright helps to facilitate digestion and reduce acid reflux, making this practice highly important for symptom control and prevention of reflux.
C. Tight-fitting clothes can increase abdominal pressure, which may contribute to the occurrence of acid reflux. While this is a helpful instruction to prevent exacerbation of symptoms, it may not be as directly impactful as remaining upright after meals.
D. Smoking can weaken the lower esophageal sphincter (LES), making it easier for stomach acid to reflux into the esophagus. However, while important, this instruction might be considered a secondary priority compared to immediate practical strategies like maintaining an upright position after eating.

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The drainage in the chest tube of a client with emphysema has changed from viscous green to clear watery fluid. Which action is best for the nurse to tak?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse identifies that the client is having a tonic clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/minute. The nurse calls for help and 2 other nurses enter the room. Which 3 interventions should be performed first?

Correct Answer is ["B","C","E"]

Explanation

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Correct Answer is B

Explanation

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