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 B

Explanation

Choice A reason: Troubleshooting the ventilator delays oxygenation in a patient with acute lung failure. Manual ventilation ensures immediate breathing, making this incorrect, as it’s less urgent than the nurse’s priority to maintain the patient’s airway and oxygenation during an alarm.

Choice B reason: Manually ventilating the patient after disconnecting from the inoperative ventilator ensures oxygenation in acute lung failure. This aligns with emergency respiratory protocols, making it the correct first action the nurse should take to address the ventilator alarm.

Choice C reason: Calling the respiratory therapist is important but delays immediate oxygenation needed during a ventilator failure. Manual ventilation is the priority, making this incorrect, as it postpones the nurse’s critical action to ensure the patient’s breathing is supported.

Choice D reason: Silencing alarms without addressing the ventilator failure risks hypoxia in a lung failure patient. Manual ventilation is urgent, making this incorrect, as it’s unsafe compared to the nurse’s priority of ensuring oxygenation during the inoperative alarm.

A. “The operating room is prepared; let’s not keep the surgeon waiting.” B. “You have the right to cancel surgery, but it could be weeks before you are rescheduled.” C. “You sound frightened; tell me what you are thinking.” D. “Your preoperative medications will have you feeling more relaxed in a minute, it will be fine.”

Correct Answer is C

Explanation

Choice A reason: Pressuring the patient to proceed disregards her autonomy and right to revoke consent. Exploring her concerns respects her decision, making this incorrect, as it dismisses the patient’s expressed wish to cancel the mitral valve replacement surgery during transport.

Choice B reason: Highlighting rescheduling delays may coerce the patient, undermining her right to refuse. Addressing her fears validates her feelings, making this incorrect, as it prioritizes logistics over the patient’s autonomy and emotional state during the surgical consent process.

Choice C reason: Asking about the patient’s thoughts acknowledges her fear and respects her right to revoke consent, facilitating open communication. This aligns with ethical nursing practice, making it the correct response to support the patient’s decision regarding mitral valve replacement surgery.

Choice D reason: Dismissing the patient’s refusal with reassurance about medications ignores her autonomy and consent rights. Exploring her concerns is more appropriate, making this incorrect, as it fails to address the patient’s explicit wish to cancel the surgery during transport.

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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

A patient with acute lung failure has been on a ventilator for 3 days and is being considered for weaning. When entering the room, the ventilator inoperative alarm sounds. What action should the nurse take FIRST?

Correct Answer is B

Explanation

During transport to the operating room for mitral valve replacement, a patient with a signed consent form says that she does not want to go through with the surgery and asks to be returned to her room. What is the best response from the nurse?

Correct Answer is C

Explanation

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The nurse has just received a report on a group of clients on the neurosurgical unit. Which client is the nurse’s first priority?

You are the charge nurse in a busy med-surg unit. There are several patients under your care, and you are managing a group of nurses. Which patient should be prioritized for immediate intervention?

Which situations are early signs of an ethical dilemma? (Select all that apply)

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