A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response?
'It is unnecessary for you to go to the restroom at this time."
'I can assist you to the bathroom and back to bed."
'I cannot assist you at this time, please wait until I finish what I’m doing”.
'You cannot go to the bathroom.'
The Correct Answer is B
Chest tubes are inserted to drain fluid, blood, or air from the pleural space, which is the space between the lung and the chest wall. It is important to ensure that the chest tube is secured properly and the drainage system is functioning properly before the patient is ambulated. Additionally, the patient may experience discomfort or pain during ambulation, so it is important to assess and manage the patient's pain before and after ambulation.
Option A is not appropriate because it disregards the patient's need to use the restroom and may make the patient feel helpless or dependent.
Option c is not appropriate because it does not address the patient's request for assistance and may make the patient feel neglected or uncared for.
Option d is not appropriate because it is a directive statement that does not take into account the patient's autonomy or individual needs. It is important to involve the patient in the decision-making process and provide appropriate care based on their individual needs and preferences.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
: A client with renal disease may have impaired kidney function, which can affect fluid balance in the body. Giving fluids too quickly or increasing the infusion rate too quickly can lead to fluid overload,
which can exacerbate the client's condition. It is important for the nurse to monitor the amount of fluid the client is receiving to ensure that the infusion rate is appropriate for the client's condition and to prevent fluid overload. Checking the intravenous rate every two days is not sufficient; the nurse should monitor the rate regularly and adjust it as necessary based on the client's response.
Correct Answer is A
Explanation
The use of an incentive spirometer is essential after surgery to prevent complications such as pneumonia and atelectasis. Atelectasis is the collapse of air sacs in the lungs, which can occur after surgery due to decreased respiratory effort and shallow breathing. An incentive spirometer helps the patient take deep breaths and increase their lung volume, preventing these complications.
Breathing rapidly to prevent pneumonia (option b) is not recommended as it can lead to hyperventilation and other respiratory complications.
Option c is incorrect because patient education is a crucial aspect of post-operative care, and the patient needs to be aware of the potential complications and how to prevent them.
The use of a chest tube (option d) is not usually required after hip surgery, and it is not a priority teaching for the patient.
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