A nurse is assisting in the care of a client.
Admission Assessment.
1500: Client transferred from postanesthesia care unit, following a left lung lobectomy.
Client alert and oriented to person, place, time,. and situation.
Reports pain as 3 on a scale of 0 to 10. Dressing dry and intact to left chest.
Water seal chest tube drainage system has 100 mL sanguineous drainage.
Right lung sounds clear.
Left lung sounds diminished.
For each potential nursing action, click to specify if the potential action is. indicated or contraindicated for the client who has a chest tube.
Clamp chest tube when client ambulates.
Report burning pain in chest to provider.
Reinforce dressing around the tube as needed if it loosens.
Strip the tubing twice daily to ensure patency.
Maintain chest tube below the chest.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}
Clamp chest tube when client ambulates. Contraindicated. Clamping the chest tube can cause a tension pneumothorax, which is a life-threatening condition. The chest tube should be kept open and patent at all times, unless ordered by the provider for a specific reason. Report burning pain in chest to provider. Indicated.
Burning pain in the chest may indicate an infection, inflammation, or injury to the pleura or lung tissue. The provider should be notified of any changes in the client’s pain or discomfort.
Reinforce dressing around the tube as needed if it loosens. Indicated. The dressing around the chest tube should be kept dry and intact to prevent air leaks and infection. If the dressing becomes loose, wet, or soiled, it should be reinforced with sterile gauze and tape.
Strip the tubing twice daily to ensure patency. Contraindicated. Stripping or milking the tubing can cause increased negative pressure in the chest cavity, which can damage the lung tissue and impair gas exchange. The tubing should be assessed for kinks, clots, or obstructions, and gently tapped or repositioned if needed.
Maintain chest tube below the chest. Indicated. The chest tube should be kept below the level of the chest to facilitate drainage by gravity and prevent backflow of fluid into the pleural space.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D: "My partner will use condoms with spermicides.”
Choice A rationale:
"My partner and I will use petroleum jelly with latex condoms.” This statement is incorrect because petroleum jelly can degrade latex condoms, making them more likely to break. It’s important to use water-based or silicone-based lubricants with latex condoms to maintain their integrity and effectiveness.
Choice B rationale:
"My partner and I will both use a condom during intercourse.” Using two condoms at once, also known as ‘double-bagging’, is not recommended as it can increase the friction between the condoms and lead to breakage. Therefore, this statement does not indicate an understanding of proper condom use.
Choice C rationale:
"I will be able to remove my contraceptive sponge immediately after intercourse.” The contraceptive sponge should be left in place for at least 6 hours after intercourse to ensure effectiveness, but not more than 30 hours in total. Immediate removal does not provide the necessary time for the spermicide in the sponge to deactivate the sperm.
Choice D rationale:
"My partner will use condoms with spermicides.” This statement is correct. Condoms with spermicides provide an additional layer of contraceptive protection by combining the barrier method with a chemical that deactivates sperm. This indicates an understanding of the teaching on effective contraceptive practices.
Correct Answer is C
Explanation
Choice A rationale:
"Provide homeschooling for your child" is not relevant information for the guardians of a child with cystic fibrosis. The primary focus should be on managing the child's medical condition and providing appropriate care rather than discussing education settings.
Choice B rationale:
"Do not include your child when making decisions about treatment" is not appropriate advice. Involving the child in age-appropriate discussions about their treatment and healthcare decisions can empower them and promote their understanding and cooperation with the treatment plan. It is essential to engage children in their care to the extent possible, with guidance from healthcare providers.
Choice C rationale:
"Have your child wear a medical identification wristband" is the correct choice. Children with cystic fibrosis may have specific medical needs or allergies that emergency responders need to be aware of in case of emergencies. A medical identification wristband can provide crucial information about the child's condition and help ensure that they receive appropriate care in emergencies.
Choice D rationale:
"Ensure that your child does not receive the influenza vaccine annually" is not the recommended advice. Children with cystic fibrosis are at higher risk of respiratory infections, and the annual influenza vaccine is generally recommended to help prevent such infections. However, specific medical recommendations may vary, so it's essential for the guardians to follow the guidance of their child's healthcare provider regarding vaccinations.
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