A nurse has just received report on 4 clients who all have chest tubes in place. Which client is the priority to see first?
The client with suction pressure set at -20 cmH2O.
The client with bubbling in the drainage tubing.
The client whose drainage system is standing on the floor.
The client with continuous bubbling in the drainage chamber.
The Correct Answer is D
Choice A reason: Suction pressure at -20 cmH2O is standard for chest tubes and not an immediate concern. Continuous bubbling suggests a pneumothorax, making this incorrect, as it’s a normal setting compared to the priority of addressing a potential air leak in the system.
Choice B reason: Bubbling in the drainage tubing is normal with fluid movement, not indicating an issue. Continuous bubbling in the chamber suggests an air leak, making this incorrect, as it’s less urgent than the priority client with a potential pneumothorax requiring immediate assessment.
Choice C reason: A drainage system on the floor risks tipping but is less urgent than continuous bubbling indicating an air leak. The pneumothorax risk takes precedence, making this incorrect, as it’s a secondary issue compared to the priority client’s chest tube complication.
Choice D reason: Continuous bubbling in the drainage chamber suggests an air leak or pneumothorax, a critical complication requiring immediate assessment. This aligns with chest tube management priorities, making it the correct client for the nurse to see first to address a potential emergency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E"]
Explanation
Choice A reason: Fluid and nutrition support overall health but aren’t direct outcomes for peripheral perfusion in artery disease. Warm skin and palpable pulses indicate improved circulation, making this incorrect, as it’s not specific to the nursing diagnosis of ineffective tissue perfusion.
Choice B reason: Adequate urinary output reflects renal perfusion, not peripheral artery disease’s limb perfusion. Palpable pulses are more relevant, making this incorrect, as it does not directly address the peripheral tissue perfusion outcome in the client’s nursing care plan.
Choice C reason: Respiratory distress is unrelated to peripheral artery disease, which affects limb circulation. Warm, dry skin is a perfusion outcome, making this incorrect, as it does not pertain to the nursing diagnosis of ineffective tissue perfusion in the client’s extremities.
Choice D reason: Warm and dry skin indicates improved peripheral perfusion in artery disease, reflecting better blood flow. This aligns with nursing outcomes for tissue perfusion, making it a correct outcome the nurse would expect for the client’s peripheral artery disease management.
Choice E reason: Palpable peripheral pulses demonstrate effective blood flow, a key outcome for peripheral artery disease perfusion. This aligns with vascular nursing goals, making it a correct outcome the nurse would include for the client’s ineffective tissue perfusion diagnosis.
Correct Answer is B
Explanation
Choice A reason: Evaluating pain level requires RN judgment, though assisting with ambulation is within the LPN’s scope. Medication administration is fully delegable, making this incorrect, as it includes an assessment task beyond the LPN’s role in post-operative care.
Choice B reason: Administering prescribed medication and monitoring for side effects is within the LPN’s scope, ensuring safe delegation. This aligns with post-operative care protocols, making it the correct task the nurse can safely delegate to the LPN for the knee replacement patient.
Choice C reason: A full head-to-toe assessment and identifying complications require RN expertise, exceeding LPN scope. Medication administration is appropriate, making this incorrect, as it’s an improper delegation for the nurse to assign to the LPN post-surgery.
Choice D reason: Educating on discharge instructions involves teaching and evaluation, an RN responsibility. Administering medication is within LPN scope, making this incorrect, as it’s not a safe task for the nurse to delegate to the LPN for the patient.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.