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:

Obtain a physician's order and informed consent from the patient.

Instruct the patient to exhale forcefully during the removal.

Monitor the patient's respiratory status and vital signs after the removal.

Apply an occlusive dressing with petroleum gauze over the wound site after removal.

Answer and Explanation

Correct Answer : A,C,E

Choice A rationale:

The nurse should obtain a physician's order and informed consent from the patient before removing the chest tube. Rationale: Chest tube removal is a medical procedure that requires a physician's order, and obtaining informed consent ensures that the patient is aware of the procedure and its potential risks.

Choice B rationale:

Instructing the patient to exhale forcefully during the removal is not necessary and may even be harmful. Rationale: The Valsalva maneuver, which involves forceful exhalation, can increase intrathoracic pressure and may lead to complications like pneumothorax during chest tube removal. Therefore, this action should be avoided.

Choice C rationale:

Monitoring the patient's respiratory status and vital signs after the removal is essential. Rationale: After chest tube removal, it is crucial to monitor the patient for signs of respiratory distress, such as shortness of breath or decreased oxygen saturation, and vital signs to detect any complications promptly.

Choice D rationale:

Applying an occlusive dressing with petroleum gauze over the wound site after removal is not the standard practice. Rationale: After chest tube removal, the wound site is typically left open to allow for the drainage of any residual air or fluid. Applying an occlusive dressing can trap air or fluid, leading to complications.

Choice E rationale:

Preparing sterile supplies such as a suture removal kit before the procedure is not necessary for chest tube removal. Rationale: Chest tube removal does not require suture removal or sterile supplies. It is a relatively simple procedure that involves removing the chest tube after ensuring proper lung re-expansion and securing the wound with an appropriate dressing.

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Correct Answer is D

Explanation

Choice A rationale:

Obtaining cultures from the chest tube site before insertion is not a standard nursing action during chest tube preparation. Cultures are usually taken if there is an infection or concern after the insertion.

Choice B rationale:

Applying a pressure dressing to the wound site after chest tube insertion is not a recommended practice. Airtight dressing can lead to tension pneumothorax. Instead, a sterile occlusive dressing is typically applied.

Choice C rationale:

Administering antibiotics to the patient before the procedure is not a standard nursing action during chest tube preparation. Antibiotics are usually prescribed if there is an infection after the insertion.

Choice D rationale:

Monitoring vital signs and pain level after chest tube insertion is essential to assess the patient's response to the procedure and to identify any complications, such as pneumothorax, bleeding, or infection.

Choice E rationale:

Instructing the patient to take deep breaths during the insertion is not appropriate because chest tube insertion is a sterile procedure, and patients are usually not conscious during the process. The insertion site is anesthetized, and deep breaths could compromise sterile technique and increase the risk of infection.

A. "You should walk barefoot at home to improve circulation.". B. "Inspect your feet daily, especially between the toes.". C. "Apply heating pads to your feet for warmth in cold weather.". D. "Use adhesive tape to treat any blisters or sores on your feet.".

Correct Answer is B

Explanation

Choice A rationale:

Walking barefoot at home is not advisable for a client with diabetes. It can increase the risk of injury and foot complications, as individuals with diabetes may have reduced sensation in their feet, making it difficult to detect injuries promptly.

Choice B rationale:

"Inspect your feet daily, especially between the toes.”. This is the correct choice. Daily foot inspection is crucial for early detection of any signs of injury, infection, or changes in the skin. Early intervention can prevent more severe foot complications in individuals with diabetes.

Choice C rationale:

Applying heating pads to the feet for warmth in cold weather is not recommended for individuals with diabetes, as they may have reduced sensitivity to temperature changes and can accidentally burn their feet.

Choice D rationale:

Using adhesive tape to treat blisters or sores on the feet is not advised. Any wounds or foot issues should be assessed and treated by a healthcare professional to prevent infection and promote proper healing.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is D

Explanation

A nurse is providing education to a client with diabetes on foot care. The nurse should include which statement to promote foot health?

Correct Answer is B

Explanation

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