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: 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: 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: 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: Keeping the 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 A: An abdominal binder can be worn daily to reduce the protrusion is not a correct explanation for the nurse to provide, as this is not an effective or recommended method to treat a hernia. This is a distractor choice.
Choice B: This hernia is a normal variation that resolves without treatment is a correct explanation for the nurse to provide, as this refers to an umbilical hernia, which is a common and harmless condition in infants that usually disappears by age 2. Therefore, this is the correct choice.
Choice C: The quarter should be secured with an elastic bandage wrap is not a correct explanation for the nurse to provide, as this is a folk remedy that has no scientific basis and can cause skin irritation and infection. This is another distractor choice.
Choice D: Restrictive clothing will be adequate to help the hernia go away is not a correct explanation for the nurse to provide, as this is not a proven or safe way to treat a hernia. This is another distractor choice.
Correct Answer is ["A","D","E"]
Explanation
Choice A: Obtaining postoperative vital signs for a client one day following unilateral knee arthroplasty is a nursing action that the nurse can assign to the PN, as this is a basic skill that does not require complex judgment or intervention by the registered nurse. Therefore, this is a correct choice.
Choice B: Starting the second blood transfusion for a client twelve hours following a below knee amputation is not a nursing action that the nurse should assign to the PN, as this is an advanced skill that requires close monitoring and evaluation by the registered nurse. This is an incorrect choice.
Choice C: Initiating patient controlled analgesia (PCA. pumps for two clients immediately postoperatively is not a nursing action that the nurse should assign to the PN, as this involves administering controlled substances and assessing pain levels, which are beyond the scope of practice of the PN. This is another incorrect choice.
Choice D: Performing daily surgical dressing change for a client who had an abdominal hysterectomy is a nursing action that the nurse can assign to the PN, as this is a routine task that can be done under the supervision and direction of the registered nurse. Therefore, this is another correct choice.
Choice E: Administering a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM) is a nursing action that the nurse can assign to the PN, as this is an established protocol that can be followed by the PN with appropriate documentation and reporting. Therefore, this is another correct choice.
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