A nurse is caring for a client with a chest tube in place for treatment of a hemothorax. The nurse should prioritize which nursing intervention when caring for this client?

Empty the drainage from the pleuravac at the end of each shift.

Report serosanguinous drainage in the pleuravac.

Milk the chest tube every 4 hours to dislodge clotted blood.

Assist with coughing and deep breathing exercises every hour.

Answer and Explanation

The Correct Answer is D

A. Empty the drainage from the pleuravac at the end of each shift: This is not a standard practice. Chest tube drainage systems typically have a built-in mechanism to handle drainage, and monitoring and recording the output is essential.

B. Report serosanguinous drainage in the pleuravac: Serosanguinous drainage (a mix of blood and serous fluid) can be expected in a hemothorax, especially initially. Reporting is necessary if there are significant changes in the amount or type of drainage.

C. Milk the chest tube every 4 hours to dislodge clotted blood: Milking or stripping the chest tube is generally not recommended as it can create high negative pressures that can damage lung tissue.

D. Assist with coughing and deep breathing exercises every hour: Encouraging coughing and deep breathing helps prevent atelectasis and promotes lung expansion, which is crucial for recovery from a hemothorax.

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Correct Answer is C

Explanation

A. Reports of joint pain: Joint pain is more indicative of musculoskeletal issues rather than chronic renal disease. While joint pain can occur in some types of kidney disease, progressive edema is a more specific symptom.

B. Increase in appetite: An increase in appetite is not typically associated with chronic renal disease. Instead, clients with kidney disease may experience a decrease in appetite due to various factors such as nausea, vomiting, and changes in taste.

C. Progressive edema: Progressive edema, especially in the lower extremities and around the eyes (periorbital edema), can be a significant indicator of declining kidney function. It results from fluid retention due to impaired kidney filtration.

D. Recent increase in thirst: While increased thirst can be a symptom of chronic renal disease, it is not as specific as progressive edema. Increased thirst may occur due to other conditions or factors such as diabetes mellitus or dehydration.

A. The client expresses feelings of frustration and difficulty coping with the chronic nature of RA. B. The client's C-reactive protein (CRP) levels have remained stable since the initiation of treatment. C. The client demonstrates improved range of motion in the affected joints during physical therapy sessions. D. The client's radiographic images show no progression of joint erosion compared to images from six months ago.

Correct Answer is D

Explanation

A. The client expresses feelings of frustration and difficulty coping with the chronic nature of RA: This indicates the client is struggling emotionally, which is common in chronic illnesses but does not directly reflect the effectiveness of the RA treatment regimen.

B. The client's C-reactive protein (CRP) levels have remained stable since the initiation of treatment: While stable CRP levels can indicate control of inflammation, they do not show improvement. Ideally, effective treatment would reduce CRP levels.

C. The client demonstrates improved range of motion in the affected joints during physical therapy sessions: Improved range of motion is a positive outcome, but it may not fully represent the overall effectiveness of the RA treatment, as joint damage can still progress.

D. The client's radiographic images show no progression of joint erosion compared to images from six months ago: This is the best indicator of effective RA management as it directly shows that the treatment is preventing further joint damage, which is a primary goal in managing RA.

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A nurse is caring for a client with a chest tube in place for treatment of a hemothorax. The nurse should prioritize which nursing intervention when caring for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home care visiting nurse suspects that an older adult client is developing chronic renal disease. Since the client has no history of cardiovascular disease, what data should the nurse assess further?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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