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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: Antibiotics treat infection, but fever, tenderness, and rising creatinine suggest rejection, not infection. Immunosuppression addresses rejection, making this incorrect, as it’s less likely than the nurse’s anticipation of therapy to manage transplant rejection in the client.

Choice B reason: Peritoneal dialysis is used for kidney failure, not acute transplant rejection, which causes fever and creatinine rise. Immunosuppression is needed, making this incorrect, as it’s irrelevant to the nurse’s expected treatment for the client’s post-transplant symptoms.

Choice C reason: Removing the kidney is a last resort, not the first response to rejection signs like fever and tenderness. Increased immunosuppression is standard, making this incorrect, as it’s premature compared to the nurse’s anticipation of rejection management.

Choice D reason: Increased immunosuppression treats acute transplant rejection, indicated by fever, tenderness, rising creatinine, and kidney enlargement. This aligns with post-transplant care, making it the correct treatment the nurse would anticipate for the client’s symptoms one week after transplantation.

A. Restrict fluids. B. Administer dextrose 5%. C. Administer oxygen as prescribed. D. Place a cooling blanket on the client. E. Elevate extremities if no fractures are present. F. Prepare to give oral pain medication as prescribed. G. Administer lactated Ringer’s 1 L bolus.

Correct Answer is ["C","E","G"]

Explanation

Choice A reason: Restricting fluids is contraindicated in burns, as hypovolemia requires aggressive fluid resuscitation. Administering lactated Ringer’s is correct, making this incorrect, as it’s unsafe compared to the nurse’s priority to restore volume in a burn-injured client.

Choice B reason: Dextrose 5% is not used for burn resuscitation, as it lacks electrolytes needed for fluid shifts. Lactated Ringer’s is standard, making this incorrect, as it’s inappropriate compared to the nurse’s focus on proper fluid therapy for burn management.

Choice C reason: Administering oxygen addresses potential airway compromise and hypoxia from facial and chest burns. This aligns with burn care priorities, making it a correct action the nurse would implement to ensure respiratory stability in the emergency department.

Choice D reason: A cooling blanket is not standard for partial-thickness burns; cooling is brief and initial. Elevating extremities reduces edema, making this incorrect, as it’s not a priority action compared to the nurse’s focus on burn injury management.

Choice E reason: Elevating extremities without fractures reduces edema in burned arms, improving circulation. This aligns with burn care protocols, making it a correct action the nurse would implement to manage swelling in the client with partial-thickness burns.

Choice F reason: Oral pain medication is contraindicated with facial burns due to airway risks and absorption issues. IV lactated Ringer’s is appropriate, making this incorrect, as it’s unsafe compared to the nurse’s priority for pain management in burns.

Choice G reason: Administering lactated Ringer’s 1 L bolus restores fluid volume in burn-induced hypovolemia, per resuscitation protocols. This is a correct action the nurse would implement to stabilize the client with partial-thickness burns in the emergency department.

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A nurse has just received report on 4 clients who all have chest tubes in place. Which client is the priority to see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A client is brought to the emergency department with partial-thickness burns to the face, neck, arms, and chest after trying to put out a car fire. The nurse needs to implement which nursing actions for this client? (Select all that apply)

Correct Answer is ["C","E","G"]

Explanation

A child has a 2-day history of vomiting, hypoactive bowel sounds, and an irregular pulse. Electrolyte values are sodium, 130 mEq/L; potassium, 3.3 mEq/L; calcium, 9.5 mg/dL; and HCO3, 30 mEq/L. Which of the following imbalances is the child most likely to have? (Select all that apply)

A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. The nurse would anticipate a prescription from the primary health care provider for which type of diet for this client?

A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client’s temperature is 101.2°F (38.5°C). Which nursing action is most appropriate?

The nurse in the emergency department (ED) is assessing a client with anaphylactic shock. Which of the following findings would support a diagnosis of anaphylactic shock? (Select all that apply)

A client is admitted to the ED with a burn injury. The client’s vital signs are the following: blood pressure: 72/48, heart rate: 152 beats/min, respiratory rate: 26/min. He is pale in color and the nurse is unable to feel his pedal pulses. Which action will the nurse take first?

Which actions are considered best practices for the nurse to use during the administration of parenteral potassium to a client with a serum potassium level of 1.9 mEq/L (mmol/L)? (Select all that apply)

After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client’s understanding. Which menu selection indicates that the client correctly understands the dietary teaching?

The primary health care provider has determined that a client has contracted hepatitis A based on flu-like symptoms and jaundice. Which statement made by the client supports this medical diagnosis?