A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take?
Increase the client's wall suction.
Reposition the client.
Clamp the client's chest tube.
Strip the client's chest tube.
The Correct Answer is B
Repositioning the client is the appropriate action for the nurse to take, as chest burning may indicate that the chest tube is kinked, twisted, or compressed, which can impair drainage and ventilation. The nurse should gently move the client to a different position and check that the chest tube is not bent or occluded by clothing, bedding, or furniture. The nurse should also ensure that there are no dependent loops or coils in the tubing and that it is secured to prevent dislodgment.
a) Increasing the client's wall suction is not advisable, as it can cause increased negative pressure in the pleural space and lead to tension pneumothorax. Increasing the wall suction does not affect the patency of the chest tube or the drainage of air or fluid from the lung. The nurse should maintain the wall suction at the prescribed level and monitor for any changes in the suction chamber.
c) Clamping the client's chest tube is not advisable, as it can cause air or fluid accumulation in the pleural space and lead to tension pneumothorax. Clamping the chest tube does not relieve chest burning or improve drainage or ventilation. The nurse should only clamp the chest tube for a brief period of time and under specific circumstances, such as changing the drainage system, assessing for an air leak, or preparing for chest tube removal.
d) Stripping the client's chest tube is not advisable, as it can cause increased negative pressure in the pleural space and lead to tissue damage or bleeding. Stripping the chest tube involves applying manual pressure along the tubing to force out any clots or debris that may obstruct drainage. However, this practice is not recommended, as it can cause more harm than good. The nurse should only milk the chest tube gently and intermittently if ordered by the provider and if there is evidence of obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This response is empathetic and therapeutic, as it acknowledges the client's feelings and invites her to express her concerns. It also shows respect and interest in the client's perspective.
a) This response is false reassurance and nontherapeutic, as it dismisses the client's feelings and implies
that the surgery will solve everything.
b) This response is self-disclosure and nontherapeutic, as it shifts the focus from the client to the nurse and
does not address the client's fears.
d) This response is minimizing and nontherapeutic, as it tells the client how to feel and does not acknowledge the client's regret or anxiety.
Correct Answer is B
Explanation
Answer: B
Rationale:
A) "Expect your sputum cultures to be negative after 6 months of therapy":
While sputum cultures may become negative after a period of effective therapy, it is not always guaranteed to happen within exactly 6 months. Tuberculosis (TB) treatment usually involves several months of medication, and sputum cultures are monitored periodically to assess treatment efficacy, not solely at the 6-month mark.
B) "Drink at least 8 ounces of water when you take the pyrazinamide tablet":
Drinking plenty of water with pyrazinamide is important to prevent dehydration and to help minimize potential side effects, such as hyperuricemia or gout. Adequate hydration can also aid in the effective elimination of the medication from the body, thus reducing the risk of adverse effects.
C) "Provide a sputum specimen every 2 weeks to the clinic for testing":
Sputum specimens are typically provided less frequently than every 2 weeks, usually monthly, to monitor the progress of TB treatment. Testing frequency may vary depending on the client's condition and the healthcare provider's recommendations.
D) "Take isoniazid with an antacid":
Isoniazid should not be taken with antacids, as antacids can interfere with the absorption of isoniazid. It is usually advised to take isoniazid on an empty stomach, and clients should be instructed to wait at least 1 hour after taking isoniazid before consuming antacids.
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