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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Initiate and maintain supplemental oxygen as prescribed: Supplemental oxygen helps improve oxygenation but does not directly address the underlying issue of retained secretions. Oxygen delivery is important, but secretion removal is the priority when the airway is obstructed.

B. Plan activities with rest periods to conserve oxygen needs: While energy conservation is useful for managing oxygen demand in alert clients, it does not apply to an unresponsive client. Additionally, it does not assist with clearing the airway or managing retained secretions.

C. Provide nasotracheal suctioning as needed to remove secretions: Suctioning is the most appropriate intervention for an unresponsive client with retained secretions, as they are unable to cough or clear their own airway. This intervention directly supports airway clearance and improves ventilation.

D. Monitor oxygenation (the oxygen saturation [SaO2]) during activity: Monitoring oxygen saturation is helpful for evaluating respiratory status, but this intervention does not address the immediate problem of retained secretions compromising airway clearance.

A. 2-3 days B. 24 hours C. 1week D. 1 month

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.

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A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select 2 manifestations that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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