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 ["A","B","C","D","E"]

Explanation

A. Allergic rhinitis: This is a common manifestation of a type I hypersensitivity reaction, often involving nasal congestion, sneezing, and itching.

B. Cough: While a cough can occur, it is not as specific or common in the context of systemic type I hypersensitivity reactions as the other options.

C. Hypotension: Hypotension can occur due to vasodilation and increased vascular permeability, which are hallmarks of systemic anaphylaxis.

D. Wheezing: Wheezing results from bronchoconstriction, a common feature in systemic type I hypersensitivity reactions, such as anaphylaxis.

E. Urticaria: Urticaria (hives) is a common skin manifestation of a type I hypersensitivity reaction, characterized by itchy, raised welts on the skin.

A. pH 7.42, PaCO2 48 mm HG, HCO3 25 mEq/L B. pH 7.28, PaCO2 63 mm HG, HCO3 22 mEq/L C. pH 7.49, PaCO2 30 mm Hg, HCO3 35 mEq/L D. pH 7.36; PaCO2 42 mm Hg, HCO3 26 mEq/L

Correct Answer is B

Explanation

A. This result shows a slightly elevated PaCO2, which could suggest respiratory compensation for a metabolic alkalosis, not acidosis, as the pH is within the normal range.
B. This result indicates both a low pH and an elevated PaCO2, which are consistent with respiratory acidosis. The low HCO3 also suggests a metabolic acidosis component, making it the best match for a client with acidosis.

C. The elevated pH indicates alkalosis. The low PaCO2 and high HCO3 further suggest a primary respiratory alkalosis with metabolic compensation.
D. These values are within normal limits, indicating neither acidosis nor alkalosis.

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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 client is noted to have type I hypersensitivity reaction with a systemic response. Which clinical manifestations should the nurse anticipate? (Select all that apply).

Correct Answer is ["A","B","C","D","E"]

Explanation

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Correct Answer is B

Explanation

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