A client with a chest tube reports severe dyspnea, absent breath sounds on the affected side, and jugular venous distension. The nurse assesses increased intrathoracic pressure. What is the appropriate nursing action?

Administer diuretics to reduce the fluid accumulation.

Prepare for needle decompression or chest tube insertion.

Position the client in a Trendelenburg position to facilitate breathing.

Instruct the client to take slow, deep breaths to prevent further complications.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Administering diuretics to reduce fluid accumulation is incorrect. Severe dyspnea, absent breath sounds, and jugular venous distension indicate a potential tension pneumothorax or hemothorax, which requires prompt action, and diuretics would not address the underlying issue.

Choice B rationale:

Preparing for needle decompression or chest tube insertion is the appropriate nursing action. The client's symptoms of severe dyspnea, absent breath sounds, jugular venous distension, and increased intrathoracic pressure suggest a possible tension pneumothorax or hemothorax. Immediate decompression with a large-bore needle or insertion of a chest tube is necessary to relieve pressure and restore lung function.

Choice C rationale:

Positioning the client in a Trendelenburg position to facilitate breathing is incorrect. In the case of increased intrathoracic pressure, this position can further compromise respiratory function and is not recommended.

Choice D rationale:

Instructing the client to take slow, deep breaths to prevent further complications is incorrect. The client's condition requires urgent medical intervention, and slow, deep breaths would not address the acute issue of increased intrathoracic pressure and compromised lung function.

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Correct Answer is C

Explanation

Choice A rationale:

Increased insulin production is not the primary cause of elevated blood sugar levels and excessive thirst in a client with diabetes. In fact, in type 1 diabetes, there is a lack of insulin production, while in type 2 diabetes, there is insulin resistance, both leading to inadequate cellular uptake of glucose.

Choice B rationale:

Decreased glucose production by the liver is also not the primary cause of the symptoms. In diabetes, the liver can overproduce glucose, especially in the fasting state, contributing to hyperglycemia.

Choice C rationale:

Inadequate cellular uptake of glucose is the correct choice. In diabetes, the body's cells do not effectively utilize glucose due to either insufficient insulin or insulin resistance, leading to high blood sugar levels in the blood.

Choice D rationale:

Overproduction of glucagon by the pancreas is not the primary cause of elevated blood sugar levels and excessive thirst. Glucagon, a hormone produced by the pancreas, raises blood sugar levels when necessary, but it is not the main culprit in diabetes.

A. "You should walk barefoot at home to improve circulation.". B. "Inspect your feet daily, especially between the toes.". C. "Apply heating pads to your feet for warmth in cold weather.". D. "Use adhesive tape to treat any blisters or sores on your feet.".

Correct Answer is B

Explanation

Choice A rationale:

Walking barefoot at home is not advisable for a client with diabetes. It can increase the risk of injury and foot complications, as individuals with diabetes may have reduced sensation in their feet, making it difficult to detect injuries promptly.

Choice B rationale:

"Inspect your feet daily, especially between the toes.”. This is the correct choice. Daily foot inspection is crucial for early detection of any signs of injury, infection, or changes in the skin. Early intervention can prevent more severe foot complications in individuals with diabetes.

Choice C rationale:

Applying heating pads to the feet for warmth in cold weather is not recommended for individuals with diabetes, as they may have reduced sensitivity to temperature changes and can accidentally burn their feet.

Choice D rationale:

Using adhesive tape to treat blisters or sores on the feet is not advised. Any wounds or foot issues should be assessed and treated by a healthcare professional to prevent infection and promote proper healing.

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A client with a chest tube reports severe dyspnea, absent breath sounds on the affected side, and jugular venous distension. The nurse assesses increased intrathoracic pressure. What is the appropriate nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with diabetes who presents with elevated blood sugar levels and excessive thirst. The nurse understands that these symptoms are primarily caused by:

Correct Answer is C

Explanation

A nurse is providing education to a client with diabetes on foot care. The nurse should include which statement to promote foot health?

Correct Answer is B

Explanation

A nurse caring for a patient with a chest tube notices a sudden decrease in drainage with pink frothy sputum and crackles on auscultation. What condition should the nurse suspect, and what intervention is appropriate?

A client with a chest tube shows signs of infection, such as fever, chills, increased white blood cell count, and purulent drainage. What intervention should the nurse prioritize?

A client diagnosed with diabetes asks the nurse about dietary recommendations. The nurse should advise the client to limit the intake of which of the following foods? Select all that apply:

A client with diabetes reports feeling shaky, weak, and dizzy. The nurse suspects hypoglycemia. Which statement by the client supports this suspicion?

A nurse is educating a patient and their family about chest tube care. What instructions should the nurse include?

A nurse is preparing to remove a chest tube from a patient. Which of the following actions should the nurse take during the removal procedure? Select all that apply:

A client with a chest tube reports severe dyspnea, absent breath sounds on the affected side, and jugular venous distension. The nurse assesses increased intrathoracic pressure. What is the appropriate nursing action?

A client with diabetes is experiencing frequent episodes of hypoglycemia. The nurse should recommend which of the following strategies to prevent hypoglycemic episodes?