A nurse is caring for a patient with a chest tube connected to wall suction due to a right-sided pneumothorax. The patient reports a sensation of chest burning.
What should the nurse do next?

Clamp the patient’s chest tube.

Increase the patient’s wall suction.

Strip the patient’s chest tube.

Reposition the patient.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Clamping the patient’s chest tube is not the appropriate action. Clamping the tube can lead to tension pneumothorax, which is a life-threatening condition.

Choice B rationale

Increasing the patient’s wall suction is not the correct action. The sensation of chest burning is not related to the level of suction. Increasing the suction could potentially cause more harm.

Choice C rationale

Stripping the patient’s chest tube is not recommended. This action can cause negative pressure in the chest and can lead to injury of the lung tissue.

Choice D rationale

Repositioning the patient is the correct action. The sensation of chest burning could be due to the position of the chest tube. Repositioning the patient may alleviate the discomfort.

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Correct Answer is C

Explanation

Choice A rationale

Encouraging self-care is important, but it may not be the immediate priority if the patient is exhibiting manic behavior and has recently experienced significant personal stressors.

Choice B rationale

Assisting the patient in identifying coping behaviors is a key part of treatment, but it may not be the immediate priority if the patient is at risk of self-harm.

Choice C rationale

Preventing self-directed violence is the priority action. Patients exhibiting manic behavior may have impaired judgment and impulse control, putting them at risk of self-harm.

Choice D rationale

Identifying support systems is important, but it may not be the immediate priority if the patient is at risk of self-harm.

A. Identity vs. role confusion B. Trust vs. mistrust C. Industry vs. inferiority D. Autonomy vs. shame and doubt E. Initiative vs. guilt

Correct Answer is B,D,E,C,A

Explanation

The correct order of Erikson’s stages of psychosocial development from birth to adolescence is:

Trust vs. mistrust
Autonomy vs. shame and doubt
Initiative vs. guilt
Industry vs. inferiority
Identity vs. role confusion

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A nurse is caring for a patient with a chest tube connected to wall suction due to a right-sided pneumothorax. The patient reports a sensation of chest burning.What should the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a patient exhibiting manic behavior.The patient reports recent personal stressors, including the loss of her mother and a divorce. What should be the nurse’s priority action?

Correct Answer is C

Explanation

A nurse has accepted a position on a pediatric unit and is learning about psychosocial development. Arrange Erikson’s stages of psychosocial development in order from birth to adolescence.

Correct Answer is B,D,E,C,A

Explanation

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A nurse is caring for a patient with a chest tube connected to wall suction due to a right-sided pneumothorax. The patient reports a sensation of chest burning.
What should the nurse do next?