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 A
Explanation
Radiation therapy can cause immunosuppression, which increases the risk of infection. The nurse should monitor the client for signs of infection such as fever, chills, malaise, or purulent drainage.
- Examine the skin for generalized urticaria. This is not a common side effect of radiation therapy, as urticaria is an allergic reaction that causes hives or welts on the skin. Radiation therapy can cause localized skin irritation, erythema, or dryness, but not generalized urticaria.
- Review laboratory test results for low hemoglobin. This is not a direct effect of radiation therapy, as hemoglobin is a component of red blood cells that carries oxygen in the blood. Radiation therapy can cause anemia, which is a low number of red blood cells, but not necessarily low hemoglobin.
- Monitor the mouth for signs of xerostomia. This is not relevant for a client who receives radiation therapy to treat lung cancer, as xerostomia is dry mouth caused by reduced salivary gland function. This can occur in clients who receive radiation therapy to treat head and neck cancer, but not lung cancer.
Correct Answer is A
Explanation
Using a bronchodilator 1 hour before eating can help reduce dyspnea and improve appetite for a client who has COPD. It can also facilitate oxygen delivery to the tissues and prevent hypoxia.
b) Eating 3 large meals each day is not recommended for a client who has COPD, as it can cause abdominal distension and increase pressure on the diaphragm, leading to dyspnea and fatigue. A better option is to eat 5 to 6 small meals throughout the day.
c) Limiting water intake with meals is not advisable for a client who has COPD, as it can cause dehydration and increase the viscosity of secretions, making them harder to expectorate. A better option is to drink at least 2 L of fluids per day, preferably between meals.
d) Reducing protein intake is not beneficial for a client who has COPD, as protein is essential for maintaining muscle mass and strength, especially of the respiratory muscles. A better option is to increase protein intake to at least 1.2 g/kg of body weight per day.
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