A nurse is educating a patient and their family about chest tube care. What instructions should the nurse include?

"You should keep the drainage system below the chest level at all times.".

"Deep breathing and coughing exercises are not necessary while the chest tube is in place.".

"Notify the physician immediately if you observe any subcutaneous emphysema around the chest tube site.".

"You can expect the drainage color to change from serosanguineous to bright red during the recovery process.".

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The nurse should instruct the patient and their family to keep the drainage system below the chest level at all times. This positioning helps ensure proper drainage of fluid or air from the chest, preventing any backflow or obstruction in the system. Gravity assists in maintaining the drainage flow, promoting the effectiveness of the chest tube.

Choice B rationale:

Deep breathing and coughing exercises are essential while the chest tube is in place. These exercises help prevent complications such as atelectasis and pneumonia by promoting lung expansion and clearing secretions. The patient should be encouraged to perform these exercises as directed by the healthcare provider.

Choice C rationale:

The nurse should educate the patient and their family to notify the physician immediately if they observe any subcutaneous emphysema around the chest tube site. Subcutaneous emphysema is a potential complication of chest tube placement, indicating air leakage into the tissues. Prompt notification allows for timely intervention to prevent further complications.

Choice D rationale:

The nurse should inform the patient that the drainage color may change from serosanguineous (pale, pink, or slightly bloody) to bright red during the recovery process. Initially, the drainage may be bloody, but as healing progresses, it should become clearer. However, if the drainage suddenly becomes bright red, it could indicate active bleeding, and the healthcare provider should be notified immediately.

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Correct Answer is A

Explanation

Choice A rationale:

The nurse should suspect tension pneumothorax in the patient with a chest tube who shows sudden decreased drainage, pink frothy sputum, and crackles on auscultation. Tension pneumothorax is a life-threatening condition where air accumulates in the pleural space, leading to increased pressure on the affected lung and heart. Immediate intervention, such as chest tube insertion on the affected side, is crucial to relieve the pressure and improve ventilation.

Choice B rationale:

Subcutaneous emphysema does not present with decreased drainage or pink frothy sputum. It is characterized by air trapped under the skin, causing a crackling sensation on palpation. Monitoring respiratory status and elevating the head of the bed are appropriate interventions for subcutaneous emphysema but not in this scenario.

Choice C rationale:

Re-expansion pulmonary edema is a rare complication that occurs after rapid lung re-expansion. It does not typically manifest with pink frothy sputum and crackles. Administering diuretics may be appropriate, but it is not the primary intervention in this situation.

Choice D rationale:

Infection does not explain the sudden decrease in drainage and pink frothy sputum. Although obtaining cultures from the chest tube site is important to assess for infection, it is not the most appropriate intervention at this moment. The priority is to address the potential tension pneumothorax.

A. Assessing the client's blood pressure. B. Monitoring the client's blood glucose levels. C. Asking the client about any allergies. D. Checking the client's oxygen saturation.

Correct Answer is B

Explanation

Choice B rationale:

The nurse should prioritize monitoring the client's blood glucose levels before administering insulin. It is essential to know the client's current blood sugar level to determine the appropriate dose of insulin to administer safely. Giving insulin without knowing the current blood glucose level can lead to hypoglycemia or hyperglycemia, both of which can be dangerous for the client.

Choice A rationale:

Assessing the client's blood pressure is important but not the priority before administering insulin. High or low blood pressure can be a concern in clients with diabetes, but checking blood glucose levels takes precedence when preparing to administer insulin.

Choice C rationale:

Asking the client about any allergies is a good practice before administering any medication, but it is not the priority in this situation. The immediate concern is to address the hyperglycemia with insulin while ensuring the client's safety.

Choice D rationale:

Checking the client's oxygen saturation is not directly related to insulin administration for diabetes. It may be relevant in certain medical conditions or emergencies, but it is not a priority action before giving insulin.

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A nurse is educating a patient and their family about chest tube care. What instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for a patient with a chest tube notices a sudden decrease in drainage with pink frothy sputum and crackles on auscultation. What condition should the nurse suspect, and what intervention is appropriate?

Correct Answer is A

Explanation

A nurse is preparing to administer insulin to a client with diabetes. Before administering the insulin, the nurse should prioritize which action?

Correct Answer is B

Explanation

A client with a chest tube reports severe dyspnea, absent breath sounds on the affected side, and jugular venous distension. The nurse assesses increased intrathoracic pressure. What is the appropriate nursing action?

A nurse is preparing to remove a chest tube from a patient. Which of the following actions should the nurse take during the removal procedure? Select all that apply:

A client diagnosed with diabetes asks the nurse about dietary recommendations. The nurse should advise the client to limit the intake of which of the following foods? Select all that apply:

A nurse is educating a patient and their family about chest tube care. What instructions should the nurse include?

A client with diabetes reports feeling shaky, weak, and dizzy. The nurse suspects hypoglycemia. Which statement by the client supports this suspicion?

A client with diabetes is admitted to the hospital with hyperglycemia. The healthcare provider prescribes regular insulin IV. The nurse should administer the insulin using which technique?

A nurse is caring for a patient with a chest tube and drainage system. The patient reports continuous bubbling in the water-seal chamber. Which of the following statements should the nurse make?

A nurse is preparing a patient for chest tube insertion. Which of the following nursing actions should the nurse take during the preparation process?