A nurse caring for a patient with a chest tube notices a sudden decrease in drainage with pink frothy sputum and crackles on auscultation. What condition should the nurse suspect, and what intervention is appropriate?

Tension pneumothorax; prepare for chest tube insertion on the affected side.

Subcutaneous emphysema; monitor respiratory status and elevate the head of the bed.

Re-expansion pulmonary edema; administer diuretics as ordered.

Infection; notify the physician and obtain cultures from the chest tube site.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The nurse should suspect tension pneumothorax in the patient with a chest tube who shows sudden decreased drainage, pink frothy sputum, and crackles on auscultation. Tension pneumothorax is a life-threatening condition where air accumulates in the pleural space, leading to increased pressure on the affected lung and heart. Immediate intervention, such as chest tube insertion on the affected side, is crucial to relieve the pressure and improve ventilation.

Choice B rationale:

Subcutaneous emphysema does not present with decreased drainage or pink frothy sputum. It is characterized by air trapped under the skin, causing a crackling sensation on palpation. Monitoring respiratory status and elevating the head of the bed are appropriate interventions for subcutaneous emphysema but not in this scenario.

Choice C rationale:

Re-expansion pulmonary edema is a rare complication that occurs after rapid lung re-expansion. It does not typically manifest with pink frothy sputum and crackles. Administering diuretics may be appropriate, but it is not the primary intervention in this situation.

Choice D rationale:

Infection does not explain the sudden decrease in drainage and pink frothy sputum. Although obtaining cultures from the chest tube site is important to assess for infection, it is not the most appropriate intervention at this moment. The priority is to address the potential tension pneumothorax.

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Correct Answer is A

Explanation

Choice A rationale:

The client's statement, "I haven't been eating much lately,”. supports the suspicion of hypoglycemia. When a person with diabetes does not eat enough, especially if they are taking insulin or certain oral medications, their blood sugar levels can drop, leading to hypoglycemia. The symptoms reported by the client, including feeling shaky, weak, and dizzy, are typical manifestations of low blood sugar.

Choice B rationale:

"I've been drinking a lot of water recently”. does not support the suspicion of hypoglycemia. This statement could indicate hyperglycemia instead, as excessive thirst (polydipsia) is a common symptom of high blood sugar in diabetes.

Choice C rationale:

"I feel tired and lethargic all the time”. is a non-specific symptom and does not directly indicate hypoglycemia. Fatigue can be caused by various factors, and in this case, there is no clear link to low blood sugar.

Choice D rationale:

"My heart has been racing throughout the day”. is also not indicative of hypoglycemia. Rapid heart rate (tachycardia) can have multiple underlying causes, and it is not a primary symptom of low blood sugar.

A. Intramuscular injection. B. Subcutaneous injection. C. Intradermal injection. D. Intravenous bolus injection. E. Intravenous infusion pump.

Correct Answer is D

Explanation

Choice D rationale:

The nurse should administer regular insulin IV using an intravenous bolus injection in this scenario. When a client with diabetes is admitted to the hospital with hyperglycemia and requires immediate correction of blood sugar levels, intravenous insulin bolus is the most appropriate technique. Intravenous administration allows for rapid action and precise control over insulin dosing.

Choice A rationale:

Intramuscular injection is not the recommended route for insulin administration in this situation. It is a slower route, and the absorption may not be predictable, which could delay the desired effect of lowering blood glucose levels.

Choice B rationale:

Subcutaneous injection is the standard method for most routine insulin administration in clients with diabetes. However, in the case of hyperglycemia requiring rapid correction, intravenous bolus injection is preferred for faster action.

Choice C rationale:

Intradermal injection is not appropriate for insulin administration. This route is typically used for skin testing or allergen sensitivity assessments, not for delivering insulin.

Choice E rationale:

While an intravenous infusion pump can be used for insulin administration in some situations, it is not the best choice for rapidly correcting hyperglycemia. Intravenous bolus injection provides a more immediate and precise response. Infusion pumps are more commonly used for continuous insulin infusions, such as in critical care settings.

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A nurse caring for a patient with a chest tube notices a sudden decrease in drainage with pink frothy sputum and crackles on auscultation. What condition should the nurse suspect, and what intervention is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with diabetes reports feeling shaky, weak, and dizzy. The nurse suspects hypoglycemia. Which statement by the client supports this suspicion?

Correct Answer is A

Explanation

A client with diabetes is admitted to the hospital with hyperglycemia. The healthcare provider prescribes regular insulin IV. The nurse should administer the insulin using which technique?

Correct Answer is D

Explanation

A client with a chest tube reports severe dyspnea, absent breath sounds on the affected side, and jugular venous distension. The nurse assesses increased intrathoracic pressure. What is the appropriate nursing action?

A client with a chest tube shows signs of infection, such as fever, chills, increased white blood cell count, and purulent drainage. What intervention should the nurse prioritize?

A nurse is educating a patient and their family about chest tube care. What instructions should the nurse include?

A nurse is responsible for chest tube care and management. Which of the following actions should the nurse perform to maintain chest tube function? Select all that apply:

A nurse is providing education to a client with diabetes on foot care. The nurse should include which statement to promote foot health?

A nurse is preparing to administer insulin to a client with diabetes. Before administering the insulin, the nurse should prioritize which action?

A nurse is caring for a client with diabetes who presents with elevated blood sugar levels and excessive thirst. The nurse understands that these symptoms are primarily caused by:

A client diagnosed with diabetes asks the nurse about dietary recommendations. The nurse should advise the client to limit the intake of which of the following foods? Select all that apply: