A nurse is caring for a client on the medical-surgical unit.

Exhibits

For each potential nursing action, click to specify if the 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.

Maintain water level at 2 cm.

Strip the tubing twice daily to ensure patency

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}

A.   Clamping the chest tube during ambulation can lead to increased intrathoracic pressure, which may cause tension pneumothorax or other complications. Chest tubes should remain unclamped to maintain proper drainage. However, it may be done briefly during tube changes or if there is a suspected air leak, always under specific medical orders.
B.   Burning pain in the chest could indicate complications such as infection or irritation at the insertion site. Reporting this symptom to the provider allows for timely assessment and intervention.
C.   A loose dressing around the chest tube can compromise the integrity of the system, leading to air leaks or contamination. Reinforcing the dressing helps maintain a sterile environment and prevents dislodgement of the tube.
D.   Maintaining the appropriate water seal level in the chest drainage system is essential for proper functioning. This prevents air from entering the pleural space while allowing drainage to occur effectively.
E.   Stripping or milking the chest tube is no longer a recommended practice as it can cause damage to the tissues and lead to airway obstruction or clot formation. Instead, gentle manipulation or rotation of the tubing may be done if there are signs of occlusion, but routine stripping is not recommended

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","C","D","G","H"]

Explanation

A. Contact precautions are not indicated based on the assessment findings provided.

Preeclampsia is primarily a hypertensive disorder of pregnancy characterized by systemic manifestations such as elevated blood pressure, proteinuria, and multiorgan involvement. It is not transmitted through direct contact, so contact precautions are unnecessary.
B. The client is exhibiting signs and symptoms consistent with preeclampsia, including right upper abdominal pain, headache, nausea, vomiting, facial edema, weight gain, and elevated blood pressure. Monitoring urinary output is essential for assessing renal function and detecting oliguria, which is a potential complication of preeclampsia.

C. a deep tendon reflex (DTR) grade of 3+ indicates a brisker than average response, which could be normal or potentially indicative of neurological hyperactivity. In such cases, creating a calming environment, which may include dimmed lighting, could potentially help in reducing stimuli that might exacerbate neurological excitability.
D. The client's blood pressure readings are elevated, indicating hypertension, which is a hallmark sign of preeclampsia. Monitoring blood pressure regularly is crucial for assessing the severity of hypertension and guiding management.
E. Amniocentesis is not indicated based on the assessment findings provided. Amniocentesis is a diagnostic procedure typically performed to obtain amniotic fluid for various purposes, such as fetal lung maturity assessment or genetic testing. In the context of preeclampsia, it is not a standard intervention.
F. Preeclampsia can have adverse effects on fetal well-being, including intrauterine growth restriction and placental insufficiency. However, an external fetal monitoring provides a more accurate assessment of fetal heart rate patterns and allows for closer monitoring of fetal status in cases of maternal hypertension.
G. Deep tendon reflexes (DTRs) are assessed to monitor for signs of neurological involvement in preeclampsia. Hyperreflexia, as indicated by a 3+ DTR bilaterally, is a characteristic finding in severe preeclampsia and may indicate central nervous system irritability.
H. Bed rest is often recommended for clients with preeclampsia to reduce physical activity and minimize the risk of complications such as eclampsia or stroke. It can help lower blood pressure and reduce the risk of placental abruption.

A. Position the client over an overbed table prior to the procedure. B. Instruct the client to empty her bladder prior to the procedure. C. Administer 1 L dextrose 5% in water IV bolus prior to the procedure. D. Initiate NPO status 4 hr prior to the procedure.

Correct Answer is B

Explanation

A. Positioning the client over an overbed table is not appropriate for a paracentesis procedure and may interfere with the procedure.
B. Emptying the bladder before the procedure helps to reduce the risk of accidental bladder puncture during paracentesis.
C. Administering IV fluids prior to the procedure is not typically indicated for a paracentesis, unless specifically ordered by the provider for hydration purposes.
D. NPO status is not typically required before a paracentesis procedure unless otherwise specified by the provider.

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A nurse is caring for a client on the medical-surgical unit. Exhibits For each potential nursing action, click to specify if the action is indicated or contraindicated for the client who has a chest tube.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply.

Correct Answer is ["B","C","D","G","H"]

Explanation

A nurse is planning care for a client who is scheduled to have a paracentesis. Which of the following actions should the nurse include in the plan of care?

Correct Answer is B

Explanation

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A nurse is caring for a client on the medical-surgical unit.

Exhibits

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