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?

Apply a pressure dressing to the wound site.

Obtain cultures from the chest tube site.

Administer oxygen to improve ventilation.

Monitor the client's vital signs and oxygen saturation.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Applying a pressure dressing to the wound site is not the priority intervention for a chest tube with signs of infection. The primary concern is to address the infection and prevent its spread.

Choice B rationale:

The nurse should prioritize obtaining cultures from the chest tube site to identify the causative organism responsible for the infection. This information will guide the selection of appropriate antibiotics to treat the infection effectively.

Choice C rationale:

Administering oxygen to improve ventilation may be beneficial for some patients, but it does not address the underlying infection. Oxygen therapy can support respiratory function but is not the priority intervention in this situation.

Choice D rationale:

Monitoring vital signs and oxygen saturation is essential but does not address the infection directly. Vital sign monitoring is ongoing, while obtaining cultures is a specific intervention targeted at the suspected infection.

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Correct Answer is D

Explanation

Choice A rationale:

Stating that continuous bubbling in the water-seal chamber is a normal finding and does not require any intervention is incorrect. Continuous bubbling indicates an air leak, and it requires prompt evaluation and intervention.

Choice B rationale:

Clamping the tubing to see if the bubbling stops is incorrect. Clamping the tubing would only be done to assess if the air leak is from the patient or the system, but it does not address the underlying issue.

Choice C rationale:

Applying an occlusive dressing to seal the wound site is incorrect. While dressing changes may be necessary to maintain a sterile environment, it will not resolve the air leak causing continuous bubbling.

Choice D rationale:

Notifying the physician immediately about the air leak is the appropriate nursing action. Continuous bubbling in the water-seal chamber suggests an air leak, which could compromise the effectiveness of the chest tube and require immediate medical attention.

A. Whole grains. B. Fruits. C. Green leafy vegetables. D. Saturated fats. E. Lean protein.

Correct Answer is ["B","D"]

Explanation

Choice A rationale:

Whole grains are generally recommended for individuals with diabetes as they provide a steady source of energy and contain fiber, which can help manage blood sugar levels.

Choice B rationale:

Fruits should be limited because they contain natural sugars, which can raise blood sugar levels. While fruits are a healthy choice, it's essential for people with diabetes to monitor their intake and choose lower-sugar options.

Choice C rationale:

Green leafy vegetables are generally encouraged for individuals with diabetes as they are low in calories and carbohydrates and have a positive impact on blood sugar levels.

Choice D rationale:

Saturated fats should be limited because they can contribute to insulin resistance and increase the risk of heart disease, which is already elevated in people with diabetes.

Choice E rationale:

Lean protein is a good choice for individuals with diabetes as it can help stabilize blood sugar levels and promote satiety without contributing to significant fluctuations in glucose.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient with a chest tube and drainage system. The patient reports continuous bubbling in the water-seal chamber. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

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:

Correct Answer is ["B","D"]

Explanation

A nurse is responsible for chest tube care and management. Which of the following actions should the nurse perform to maintain chest tube function? 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 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 diabetes reports feeling shaky, weak, and dizzy. The nurse suspects hypoglycemia. Which statement by the client supports this suspicion?

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

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 nurse is preparing to administer insulin to a client with diabetes. Before administering the insulin, the nurse should prioritize which action?

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?