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.'

Answer and Explanation

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.

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Correct Answer is A

Explanation

Pulse oximetry is a non-invasive method of monitoring the oxygen saturation level in the blood. A normal range for oxygen saturation is between 95% and 100%. An oxygen saturation level of 89% indicates hypoxemia, which is a serious condition that can lead to tissue damage, organ failure, and even death if left untreated.

Therefore, the priority nursing action is to perform a respiratory assessment to determine the cause of the hypoxemia. This should include assessing the client's airway patency, breathing patern, lung sounds, and oxygen therapy if the client is already receiving it. The nurse should also observe for any signs of respiratory distress such as cyanosis, accessory muscle use, or difficulty breathing.

While it is important to document hypoxemia and report it to the healthcare provider, the priority at this time is to assess and intervene promptly to prevent further deterioration of the client's condition. Checking the placement of the pulse oximeter may be necessary if the reading is unreliable, but it is not the priority in this scenario.

A. Tracheostomy kit setup B. Suction equipment C. Smaller Tracheostomy Tube and Same size Tracheostomy Tube D. Ambu bag E. Oxygen F. Larger Tracheostomy T

Correct Answer is ["A","B","C","D","E"]

Explanation

A tracheostomy is a surgical procedure that involves creating an opening in the neck to establish a direct airway to the trachea. It is usually done in patients who require long-term mechanical ventilation or have upper airway obstruction. In case the tracheostomy becomes dislodged, the following equipment should be available to ensure the patient's safety:

Tracheostomy kit setup: This includes a new tracheostomy tube, obturator, and other equipment necessary to replace the dislodged tracheostomy tube.

Suction equipment: Dislodgement of the tracheostomy tube can cause airway obstruction due to the presence of secretions. Suction equipment can be used to remove the secretions and prevent airway obstruction.

Smaller Tracheostomy Tube and Same size Tracheostomy Tube: If the dislodged tracheostomy tube cannot be reinserted or is damaged, having smaller and same size tracheostomy tubes available can be helpful in establishing a new airway.

Ambu bag: This is a manual resuscitation device used to provide positive pressure ventilation to the patient. It can be used in case the patient's breathing is compromised due to airway obstruction.

Oxygen: The patient may require supplemental oxygen if their breathing is compromised due to airway obstruction.

Larger Tracheostomy Tube: A larger tracheostomy tube may not be needed immediately and may be contraindicated in some cases as it can cause trauma to the tracheal wall.

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A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes that the client’s pulse oximetry is 89%. What is the priority nursing action?

Correct Answer is A

Explanation

You are setting up a room for your patient that has a new tracheostomy. Select all of the equipment you need bring with to ensure patient is safe should the tracheostomy become dislodged:

Correct Answer is ["A","B","C","D","E"]

Explanation

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