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 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. "This is a normal finding and does not require any intervention.". B. "Let me clamp the tubing to see if the bubbling stops.". C. "I'll apply an occlusive dressing to seal the wound site.". D. "Notify the physician immediately; there might be an air leak.".

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.

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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 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 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 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:

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

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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?

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

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