A nurse is caring for a client who has a newly inserted chest tube. The nurse should clarify which of the following prescriptions with the provider?
Vigorously strip the chest tube twice daily.
Assist the client out of bed three times daily.
Notify the provider when tiddling ceases.
Administer morphine 2 mg IV bolus every 3 hr. PRN for pain.
The Correct Answer is A
Choice A Reason:
Vigorously strip the chest tube twice daily. The nurse should clarify the prescription to "vigorously strip the chest tube twice daily" with the provider. Stripping or milking a chest tube is generally not recommended, as it can cause damage to the tube and lead to complications. The movement of fluid and air in the chest tube should be allowed to occur naturally based on the patient's own respiratory effort.
Choice B Reason:
Assist the client out of bed three times daily - This is a reasonable activity for a client with a chest tube, as mobility and deep breathing can help prevent complications.
Choice C Reason:
Notify the provider when tiddling ceases - Monitoring for tiddling (fluctuations in the water seal chamber with respiration) and notifying the provider when tiddling stops is important, as it might indicate a potential issue with the chest tube placement or functioning.
Choice D Reason:
Administer morphine 2 mg IV bolus every 3 hr PRN for pain - Administering pain relief for the client is appropriate and helps manage their comfort. Pain control is important to encourage deep breathing and prevent complications related to shallow breathing due to pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Placing the client in high-Fowler's position is the appropriate action. When administering peritoneal dialysis, the nurse should place the client in a high-Fowler's position. This position helps promote the flow of dialysate into and out of the peritoneal cavity and assists with proper drainage. The high-Fowler's position allows for gravity to aid in the movement of fluid and helps prevent leakage of fluid back into the catheter.
Choice B Reason:
Chilling the dialysate before administration is not necessary and could cause discomfort to the client. Dialysate should be warmed to body temperature before use.
Choice C Reason:
Hanging the drainage bag below the client's abdomen is incorrect. The drainage bag should be positioned below the level of the abdomen to allow for proper drainage by gravity, but it should not be hung too low as this can lead to excessive drainage and dehydration.
Choice D Reason:
Using clean technique to access the catheter is incorrect. Sterile technique is required when accessing the peritoneal dialysis catheter to prevent infection. Peritoneal dialysis involves direct access to the peritoneal cavity, which is considered a sterile body cavity.
Correct Answer is D
Explanation
Choice A reason:
WBC count 8,400/mm3 is not appropriate. This white blood cell count is within the normal range and is not a cause for concern.
Choice B reason:
Serosanguineous exudate noted on dressing change is not appropriate. Serosanguineous drainage is a normal finding in the early stages of wound healing and is expected after surgery.
Choice C reason:
Reports pain of 4 on a scale from 0 to 10 when coughing is not appropriate. A pain level of 4 out of 10 with coughing is a common and expected finding following an appendectomy. It's important for the nurse to assess and manage pain, but this is not an urgent concern.
Choice D reason:
Haemoglobin 10 mg/dL is appropriate. Haemoglobin level of 10 mg/dL indicates a low level of haemoglobin, which might suggest anaemia or blood loss. Reporting this finding to the provider is important as it could indicate a need for further evaluation or intervention.
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