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A nurse is assisting in the care of a client.

Exhibits

For each potential nursing action, click to specify if the potential action is. indicated or contraindicated for the client who has a chest tube.

A.

Clamp chest tube when client ambulates.

B.

Report burning pain in chest to provider.

C.

Reinforce dressing around the tube as needed if it loosens.

D.

Strip the tubing twice daily to ensure patency.

E.

Maintain chest tube below the chest.

Answer and Explanation

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.


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Related Questions

Correct Answer is D

Explanation

Choice A rationale:

While music therapy can be a helpful adjunct for pain management, it is not a replacement for all pain medications. Pain management should be individualized, and the statement that music therapy alone will eliminate the need for all medication is not accurate.

Choice B rationale:

Discontinuing music therapy when the patient is no longer responsive may not be the best approach. Music therapy can still provide comfort and support even if the patient is not responsive in the traditional sense. It should be continued if it benefits the patient.

Choice C rationale:

Playing music is not intended to increase alertness but rather to provide comfort and relaxation. This statement reflects a misunderstanding of the purpose of music therapy in pain management.

Choice D rationale:

This statement correctly indicates an understanding of the purpose of music therapy. Music can distract the patient from pain and provide a sense of comfort and relaxation without completely eliminating awareness of pain.

Correct Answer is B

Explanation

Choice A rationale:

Severe nausea and vomiting are not typically associated with an ectopic pregnancy at 8 weeks of gestation. Instead, nausea and vomiting are common symptoms of a normal intrauterine pregnancy due to hormonal changes. Ectopic pregnancies often present with different symptoms, such as pelvic pain and vaginal bleeding.

Choice B rationale:

Pelvic pain is a common and concerning symptom of an ectopic pregnancy. It occurs because the fertilized egg implants outside the uterus, usually in the fallopian tube, which can lead to pain and discomfort as the pregnancy progresses.

Choice C rationale:

Uterine enlargement greater than expected for gestational age is not a typical finding in an ectopic pregnancy. In an ectopic pregnancy, the fertilized egg implants outside the uterus, so uterine enlargement is usually not evident or is less than expected for the gestational age.

Choice D rationale:

Copious vaginal bleeding is a possible but not specific finding in an ectopic pregnancy. While vaginal bleeding can occur, it is often not as heavy as the bleeding associated with a miscarriage or a normal intrauterine pregnancy. Pelvic pain is usually the more prominent symptom.

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