A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select 2 manifestations that apply.)
Pain at the insertion site
Tracheal deviation
Drainage of 75 mL/hr
Productive sputum
sudden onset of shortness of breath
Correct Answer : B,E
A. Pain at the insertion site: Mild to moderate pain is expected after chest tube placement and should be monitored, but it does not usually require immediate intervention unless it worsens or becomes severe. It is typically managed with routine analgesics.
B. Tracheal deviation: Tracheal deviation is a late and critical sign of tension pneumothorax, which requires immediate emergency intervention. It indicates severe pressure in the pleural space that can compress major vessels and impair cardiac output.
C. Drainage of 75 mL/hr: While slightly elevated, this drainage rate may be acceptable depending on the clinical context (e.g., post-thoracic surgery). The nurse should continue monitoring, but this does not require immediate action unless drainage exceeds 100–150 mL/hr.
D. Productive sputum: Productive sputum is not unusual in patients with underlying pulmonary conditions. Unless it is accompanied by signs of infection or changes in sputum color, amount, or consistency, it does not warrant immediate action.
E. Sudden onset of shortness of breath: A sudden change in respiratory status may indicate a complication such as tube dislodgement, blockage, or recurrent pneumothorax. This requires prompt evaluation and intervention to ensure adequate oxygenation and ventilation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. 2–3 days:This is the correct time frame for interpreting a tuberculin skin test (Mantoux test). The induration response should be evaluated 48 to 72 hours after administration to ensure accurate results. Reading the test outside this window may lead to false negatives or unreliable interpretation.
B. 24 hours:Reading the skin test after only 24 hours may not allow sufficient time for the delayed hypersensitivity reaction to develop. The immune response that causes induration typically peaks at 48–72 hours.
C. 1 week:Waiting a full week exceeds the ideal time frame for interpretation. By this point, the reaction may have subsided, leading to an inaccurate or unreadable result. Follow-up must occur within 2–3 days.
D. 1 month:A return after one month is far too late to interpret the results. The test site would have long since returned to baseline, making accurate evaluation impossible and necessitating repeat testing.
Correct Answer is B
Explanation
A. Airborne:Airborne precautions are required for diseases transmitted via tiny particles that remain suspended in the air, such as tuberculosis or measles. RSV is not transmitted through airborne particles and does not require this level of isolation.
B. Contact:RSV (respiratory syncytial virus) is primarily spread through direct contact with respiratory secretions or contaminated surfaces. Therefore, contact precautions such as gloves and gowns are essential to prevent transmission.
C. Protective:Protective (or reverse) precautions are used for immunocompromised patients to protect them from external pathogens, not to isolate contagious patients. RSV patients pose a risk to others, so protective precautions are not appropriate.
D. Droplet:While RSV can be spread via large respiratory droplets, the main route is contact. Droplet precautions may be used as an adjunct, but contact precautions are the primary recommended approach.
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