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 D

Explanation

Choice A rationale:

Obtaining cultures from the chest tube site before insertion is not a standard nursing action during chest tube preparation. Cultures are usually taken if there is an infection or concern after the insertion.

Choice B rationale:

Applying a pressure dressing to the wound site after chest tube insertion is not a recommended practice. Airtight dressing can lead to tension pneumothorax. Instead, a sterile occlusive dressing is typically applied.

Choice C rationale:

Administering antibiotics to the patient before the procedure is not a standard nursing action during chest tube preparation. Antibiotics are usually prescribed if there is an infection after the insertion.

Choice D rationale:

Monitoring vital signs and pain level after chest tube insertion is essential to assess the patient's response to the procedure and to identify any complications, such as pneumothorax, bleeding, or infection.

Choice E rationale:

Instructing the patient to take deep breaths during the insertion is not appropriate because chest tube insertion is a sterile procedure, and patients are usually not conscious during the process. The insertion site is anesthetized, and deep breaths could compromise sterile technique and increase the risk of infection.

A. "You should keep the drainage system below the chest level at all times.". B. "Deep breathing and coughing exercises are not necessary while the chest tube is in place.". C. "Notify the physician immediately if you observe any subcutaneous emphysema around the chest tube site.". D. "You can expect the drainage color to change from serosanguineous to bright red during the recovery process.".

Correct Answer is A

Explanation

Choice A rationale:

The nurse should instruct the patient and their family to keep the drainage system below the chest level at all times. This positioning helps ensure proper drainage of fluid or air from the chest, preventing any backflow or obstruction in the system. Gravity assists in maintaining the drainage flow, promoting the effectiveness of the chest tube.

Choice B rationale:

Deep breathing and coughing exercises are essential while the chest tube is in place. These exercises help prevent complications such as atelectasis and pneumonia by promoting lung expansion and clearing secretions. The patient should be encouraged to perform these exercises as directed by the healthcare provider.

Choice C rationale:

The nurse should educate the patient and their family to notify the physician immediately if they observe any subcutaneous emphysema around the chest tube site. Subcutaneous emphysema is a potential complication of chest tube placement, indicating air leakage into the tissues. Prompt notification allows for timely intervention to prevent further complications.

Choice D rationale:

The nurse should inform the patient that the drainage color may change from serosanguineous (pale, pink, or slightly bloody) to bright red during the recovery process. Initially, the drainage may be bloody, but as healing progresses, it should become clearer. However, if the drainage suddenly becomes bright red, it could indicate active bleeding, and the healthcare provider should be notified immediately.

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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 preparing a patient for chest tube insertion. Which of the following nursing actions should the nurse take during the preparation process?

Correct Answer is D

Explanation

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

Correct Answer is A

Explanation

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