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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason:

Obtaining consent for surgery is the correct answer. Obtaining informed consent for surgery is a critical and ethical step to ensure the client's rights are respected and that necessary medical interventions can be performed. However, in cases where the client is unable to provide consent due to their level of intoxication, the nurse should follow established protocols for obtaining consent from a legal guardian or

Choice B reason:

Insert an NG tube is incorrect. Inserting a nasogastric (NG) tube might be a necessary step in preparing a client for surgery in certain cases, but it is not the top priority in this situation. Obtaining consent for surgery takes precedence.

Choice C reason:

Applying ant embolic stockings is incorrect. Applying ant embolic stockings, also known as compression stockings, is an important measure to prevent blood clots (deep vein thrombosis) during and after surgery. However, obtaining consent for surgery is more urgent in an emergency situation.

Choice D reason:

Inserting an indwelling urinary catheter is incorrect. Inserting a urinary catheter might be necessary to monitor the client's urinary output during surgery, but obtaining consent for surgery is the priority action.

A. A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89% B. A client who has multiple sclerosis and reports ataxia and vertigo C. A client who has left-sided paralysis and slurred speech from a prior stroke D. A client who has thrombocytopenia and reports a nosebleed

Correct Answer is A

Explanation

Choice A Reason:

A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89% is correct. The nurse should attend to the client with chronic obstructive pulmonary disease and an oxygen saturation of 89% first. Oxygen saturation levels below 90% indicate significant hypoxemia and potential respiratory distress. The client with COPD is at risk for further worsening of their condition due to inadequate oxygenation. Therefore, addressing this client's low oxygen saturation is a priority to ensure their respiratory status is stabilized.

Choice B Reason:

A client who has multiple sclerosis and reports ataxia and vertigo is incorrect. While these symptoms need assessment and care, they are not indicative of an immediate life-threatening situation.

Choice CReason:

A client who has left-sided paralysis and slurred speech from a prior stroke is incorrect., While this client requires ongoing care, the immediate concern is lower in priority compared to addressing severe hypoxemia.

Choice DReason:

A client who has thrombocytopenia and reports a nosebleed is incorrect. Although a nosebleed can be concerning due to thrombocytopenia, it is not as immediately critical as addressing severe hypoxemia.

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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?

Nursing Test Bank

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