The nurse is caring for a client who underwent a right lobectomy for lung cancer 24 hours ago and has a single chest tube on the right side. Which intervention(s) should the nurse plan to implement? Select all that apply.
Monitor collection container and replace when full.
Encourage frequent use of the incentive spirometer.
Assess area around chest tube for subcutaneous emphysema.
Keep tubing loosely coiled below the level of the chest.
Verify air bubbling present in the water seal chamber.
Correct Answer : A,B,C,D
A. Monitor collection container and replace when full: The nurse should monitor the collection container to ensure it doesn't become full, as this could cause backflow into the pleural cavity. Replacing it when full is essential to maintain proper drainage.
B. Encourage frequent use of the incentive spirometer: Using the incentive spirometer helps prevent atelectasis and pneumonia by promoting lung expansion. It is important for postoperative recovery to maintain good respiratory function.
C. Assess area around chest tube for subcutaneous emphysema: Subcutaneous emphysema can occur if air leaks into the tissues around the chest tube. The nurse should check for this condition as it could indicate complications like an air leak or pneumothorax.
D. Keep tubing loosely coiled below the level of the chest: The tubing should be positioned below the chest to facilitate gravity drainage. Keeping it loosely coiled ensures that fluid and air drain efficiently without backflow.
E. Verify air bubbling present in the water seal chamber: Continuous bubbling in the water seal chamber is not expected and may indicate an air leak. Intermittent bubbling may be normal if the lung is still re-expanding, but ongoing bubbling should be reported, not simply verified.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Yoga is not the subject of this group": This response dismisses the client's curiosity and could shut down the conversation. Shutting down the discussion abruptly can make clients feel unheard and discourage participation, hindering the therapeutic environment.
B. "What do you want to know about it?": This response validates the client's interest and encourages open discussion. The nurse can provide a brief explanation without derailing the group session.
C. "Wait, let her finish talking": This response may seem dismissive and could discourage engagement. It is important to address the interruption respectfully while also encouraging dialogue.
D. "Do not interrupt in group again": This kind of response can create a hostile environment, shut down communication, and damage the therapeutic relationship between the nurse and the clients, especially in a mental health setting where trust and open expression are vital.
Correct Answer is A
Explanation
A. "Only your son can decide to who the laboratory results can be shared with."
Since the client is 18 years old, he is legally an adult and has the right to confidentiality regarding his medical information. The nurse should inform the mother that the son must provide consent before sharing any test results with her.
B. "I can give you those results as soon as I get them back from the laboratory." The nurse cannot release the results to the mother without the client's consent, as he is an adult and his medical information is confidential.
C. "I need to wait for the results of other tests before I can share the information to you." The nurse’s ability to share the results with the mother is based on the client’s consent, not on waiting for other tests.
D. "Let us wait for the healthcare provider to come and share this information with you." While it may be helpful for the healthcare provider to discuss the results, the key issue here is the client's consent. The nurse should clarify that the client is the one who must authorize sharing the results.
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