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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Frothy sputum is a common finding in patients with left-sided heart failure. This is due to fluid accumulation in the lungs (pulmonary edema), which can cause the sputum to become frothy.
Choice B rationale
Dependent edema is more commonly associated with right-sided heart failure. It occurs due to fluid accumulation in the systemic circulation, leading to swelling in the lower extremities.
Choice C rationale
Nocturnal polyuria can occur in heart failure, but it is not a specific sign of left-sided heart failure.
Choice D rationale
Jugular venous distention is a sign of right-sided heart failure, not left-sided heart failure. It occurs due to increased pressure in the right atrium, leading to visible distention of the jugular veins.
Correct Answer is D
Explanation
Choice A rationale
While improving the patient’s communication skills is an important goal in the care of a child with hemiplegic cerebral palsy, it is not the priority goal. The priority should be based on the child’s most immediate needs and the potential for harm if those needs are not met.
Choice B rationale
Fostering self-care activities is another important goal in the care of a child with hemiplegic cerebral palsy. However, it is not the priority goal. The priority should be based on the child’s most immediate needs and the potential for harm if those needs are not met.
Choice C rationale
Providing respite services for the parents is an important aspect of care, but it is not the priority goal for the child’s care plan. The priority should be based on the child’s most immediate needs and the potential for harm if those needs are not met.
Choice D rationale
Enhancing the patient’s mobility skills is the priority goal for a child with hemiplegic cerebral palsy. Hemiplegic cerebral palsy affects one side of the body, impacting the child’s mobility.
Therefore, interventions should focus on improving mobility to enhance the child’s independence and quality of life.
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