What is the first action the nurse should take with the accidental dislodgement of a chest tube?

Call for the rapid response team and request a portable chest x-ray

Turn the suction drainage system off and auscultate breath sounds

Apply a sterile dressing and tape on three sides

Notify the healthcare provider immediately.

Answer and Explanation

The Correct Answer is C

A. Call for the rapid response team and request a portable chest x-ray: While it is important to call for help and obtain imaging if needed, the immediate action is to address the potential pneumothorax by sealing the wound. The rapid response team and chest x-ray are necessary for further assessment, but securing the wound is the priority in the moment.

B. Turn the suction drainage system off and auscultate breath sounds: Turning off the suction drainage system and auscultating breath sounds may be part of subsequent assessment and care, but these actions are secondary to stopping the entry of air into the pleural space. Auscultating breath sounds would be important after the chest tube is secured to assess for signs of pneumothorax or other complications, but it is not the first priority.

C. Apply a sterile dressing and tape on three sides: The first priority when a chest tube becomes accidentally dislodged is to seal the wound to prevent air from entering the pleural space, which could cause a pneumothorax (collapsed lung). The correct method to seal the chest tube insertion site is to apply a sterile dressing and tape it on three sides. This technique allows air to escape from the pleural space but prevents air from entering, creating a temporary "one-way valve" effect. This is crucial in stabilizing the patient until further medical intervention can be provided. The fourth side of the dressing is left open to allow for air to escape, which helps prevent a tension pneumothorax

D. Notify the healthcare provider immediately: While notifying the healthcare provider is important, securing the wound to prevent further air entry is the immediate priority. Notifying the provider can occur after the dressing is applied. Prompt action to stabilize the chest tube site is crucial to prevent further respiratory distress or complications.

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Free Nursing Study Resources

Correct Answer is ["56"]

Explanation

Calculate the infusion rate in mL/min.

The total volume to be infused is 500 mL.

The infusion time is 90 minutes.

The infusion rate = 500 mL / 90 minutes = 5.5556 mL/min.

Calculate the drip rate in gtt/min.

The drop factor is 10 gtt/mL.

We need to deliver 5.5556 mL/min.

To find the drip rate, we can set up a proportion:

10 gtt / 1 mL = x gtt / 5.5556 mL

Cross-multiplying:

x = 10 gtt/mL x 5.5556 mL = 55.5556 gtt

Round the answer to the nearest whole number.

56 gtt/min.

A. Speak slow and loud so that the client can understand speech B. Encourage the client to write questions on a white erase board C. Use pre-arranged eye signais because eye muscles remain intact D. Have the client squeeze the nurse's hand when intubated and on the ventilator

Correct Answer is C

Explanation

A. Speak slow and loud so that the client can understand speech:

While speaking slowly and clearly may help with communication in some patients with ALS, this approach is less effective as the disease progresses. As ALS advances, speech muscles become affected, and the client may be unable to speak at all, making this method inappropriate for end-stage ALS. Simply speaking louder does not address the communication needs of a client who can no longer use their voice.

B. Encourage the client to write questions on a white erase board:

While writing on a whiteboard may be an effective communication strategy in the early stages of ALS when the client still has adequate hand function, this becomes increasingly difficult as muscle weakness progresses. By the end-stage, clients may lose the ability to hold a pen or write legibly, making this method less viable as the disease advances. It is not the best option for clients with significant motor impairment.

C. Use pre-arranged eye signals because eye muscles remain intact: In clients with end-stage amyotrophic lateral sclerosis (ALS), muscle weakness and loss of voluntary control progressively affect motor functions, including the ability to speak, write, and move. However, the eye muscles are typically preserved until the later stages of the disease, allowing patients to communicate through eye movements. Pre-arranged eye signals, such as blinking for "yes" or "no" or using a system of eye movements to select letters or words, are effective ways to facilitate communication with clients who can no longer speak or write. This method respects the client's remaining abilities and allows for more effective communication, especially as the disease progresses to its final stages.

D. Have the client squeeze the nurse's hand when intubated and on the ventilator:

When a client is intubated and on a ventilator, their ability to squeeze the nurse's hand may be limited due to the sedation and ventilator settings, and they may not have sufficient motor control to respond consistently. Additionally, when intubated, respiratory effort is controlled by the ventilator, so relying on hand squeezing would not be an effective or reliable method of communication. Furthermore, ALS patients in the later stages may not have enough muscle control for this method to be practical.

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What is the first action the nurse should take with the accidental dislodgement of a chest tube?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is prescribed 500 ml of Normal Saline to be infused over 90 minutes. The drop factor on the tubing is 10 gtt/mL. At what rate should the nurse regulate the IV (gtt/min)? (Round to the nearest whole number)

Correct Answer is ["56"]

Explanation

Which method would the nurse utilize to best facilitate communication when caring for a client with end stage amyotrophic lateral sclerosis (ALS)?

Correct Answer is C

Explanation

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A client with a medical diagnosis of acute respiratory distress syndrome (ARDS) is being placed in the prone position. The nurse explains to family members that, "This will help improve ventilation by:

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