A client with a right lateral chest tube needs to be transported for a chest x-ray. Which intervention is most important for the nurse to implement?

Medicate for pain prior to moving the client.

Keep the drainage system below the insertion site.

Send the client to radiology via stretcher.

Mark the drainage amount on the collection chamber.

Answer and Explanation

The Correct Answer is B

Rationale:
A. Medicate for pain prior to moving the client: Pain control improves comfort and cooperation during transport, but it does not directly prevent a life-threatening complication related to chest tube function during movement.

B. Keep the drainage system below the insertion site: Maintaining the drainage system below chest level prevents backflow of air or fluid into the pleural space, which could cause a pneumothorax or compromise lung re-expansion during transport.

C. Send the client to radiology via stretcher: A stretcher is appropriate for safety, but it does not address the priority risk associated with chest tube mechanics and pleural pressure changes.

D. Mark the drainage amount on the collection chamber: Tracking output is important for ongoing assessment, but it is not the most immediate intervention required to ensure chest tube safety during transport.

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Correct Answer is C

Explanation

Rationale:
A. Report signs of increasing irritability: Changes in mental status, such as irritability, can indicate worsening hyponatremia. While important to monitor, this is a symptom rather than a direct measure of the client’s condition.

B. Administer a PRN antiemetic: Anti-nausea medication may relieve symptoms but does not address the underlying electrolyte imbalance or prevent complications of SIADH. It is supportive care, not a priority intervention.

C. Monitor serum sodium levels: Hyponatremia is the hallmark of SIADH and can lead to seizures, coma, or death if severe. Frequent monitoring of serum sodium is critical to guide fluid restriction, hypertonic saline administration, and other interventions, making it the most important nursing action.

D. Assess for peripheral edema daily: SIADH typically causes water retention without significant peripheral edema because fluid accumulates intracellularly rather than in the interstitial space. Monitoring edema is less critical than tracking serum sodium.

A. Check the endotracheal tube cuff pressure. B. Administer a PRN sedative. C. Assess client for trauma to the tongue. D. Prepare for urgent reintubation.

Correct Answer is A

Explanation

Rationale:
A. Check the endotracheal tube cuff pressure: An audible gurgling sound from the mouth after intubation indicates an air leak around the endotracheal tube cuff. Inadequate cuff inflation allows air to escape during ventilation, producing this sound. Verifying and correcting cuff pressure helps ensure an effective seal and adequate ventilation.

B. Administer a PRN sedative: Sedation may be indicated for comfort or ventilator synchrony, but it does not address the mechanical cause of an audible air leak. The presence of bilateral breath sounds and absence of epigastric gurgling suggest correct tube placement. Sedation without correcting the cuff issue could delay appropriate airway management.

C. Assess client for trauma to the tongue: Tongue trauma can occur during intubation, but it would not cause gurgling related to ventilation. The described findings point toward an airway seal problem rather than oral injury. Airway patency and ventilation effectiveness take priority.

D. Prepare for urgent reintubation: Reintubation is indicated if tube placement is incorrect or ventilation is ineffective. Bilateral breath sounds and absence of gastric sounds confirm tracheal placement. The issue is more consistent with a cuff leak, which should be addressed before considering reintubation.

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A client with a right lateral chest tube needs to be transported for a chest x-ray. Which intervention is most important for the nurse to implement?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone secretion (SIADH) who was admitted to the intensive care unit (ICU) yesterday. Which intervention is most important for the nurse to include in the client's plan of care (POC)?

Correct Answer is C

Explanation

After an endotracheal intubation is performed, bilateral breath sounds can be auscultated. No epigastric gurgling can be heard, and there is an audible gurgle from the client's mouth. Which intervention should the nurse implement?

Correct Answer is A

Explanation

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