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.

Answer and Explanation

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.

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Correct Answer is ["A","C","E"]

Explanation

These are important safety and comfort measures for a client who uses home oxygen therapy via a nasal cannula.

The other options are not correct because:

b. Verify the oxygen ﬂow rate every other day. This is not frequent enough, as the ﬂow rate should be checked at least daily and whenever the client feels short of breath or has changes in vital signs.

d. Apply petroleum ointment to nares if they become dry and irritated. This is not recommended, as petroleum products can ignite in the presence of oxygen and cause burns or fire. A water-based lubricant should be used instead.

A. Oxygen saturation level 96% B. Respiratory alkalosis C. Increased anteroposterior diameter of the chest D. Petechiae on chest

Correct Answer is C

Explanation

Increased anteroposterior diameter of the chest, also known as barrel chest, is a common finding in clients who have COPD with emphysema. It is caused by chronic air trapping and hyperinﬂation of the lungs, which results in fattening of the diaphragm and widening of the rib cage.

a) Oxygen saturation level 96% is within the normal range of 95% to 100% and does not indicate hypoxemia or impaired gas exchange. Clients who have COPD with emphysema typically have lower oxygen saturation levels, ranging from 88% to 92%.
b) Respiratory alkalosis is a condition in which the blood pH is elevated due to decreased carbon dioxide levels. It is caused by hyperventilation, which can occur in response to hypoxia, anxiety, or pain. Clients who have COPD with emphysema usually have respiratory acidosis, which is a condition in which the blood pH is lowered due to increased carbon dioxide levels. It is caused by hypoventilation, which results from impaired lung function and airway obstruction.
d) Petechiae on chest are small red or purple spots on the skin caused by bleeding from capillaries. They are not a typical finding in clients who have COPD with emphysema, unless they have severe coughing episodes or coagulation disorders. They can indicate infection, inﬂammation, trauma, or vascular disease.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via a nasal cannula. Which of the following should the nurse include in the teaching? (Select all that apply)

Correct Answer is ["A","C","E"]

Explanation

A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client?

Correct Answer is C

Explanation

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