A patient receiving treatment for a pneumothorax calls on the call light to tell you something is wrong with their chest tube. When you arrive to the room you note that the drainage system has fallen on its side and there is a large crack in the system. What is your next PRIORITY?

Place the patient in supine position and clamp the tubing.

Notify the physician immediately.

Disconnect the drainage system and get a new one.

Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.

Answer and Explanation

The Correct Answer is D

A. Clamping a chest tube is generally not recommended because it can cause tension pneumothorax if air accumulates in the pleural space. Positioning alone does not resolve the problem and may put the patient at risk.

B. While notifying the physician is important, it is not the immediate action to maintain the patient’s airway and prevent a life-threatening pneumothorax. The priority is maintaining the chest tube system function.

C. Simply disconnecting the system without providing a temporary water seal would allow air to enter the pleural space, worsening the pneumothorax and risking respiratory compromise.

D. This is the emergency measure to maintain a temporary water seal, preventing air from entering the pleural space and worsening the pneumothorax. After establishing the temporary water seal, a new chest drainage system can be connected. This intervention prevents life-threatening complications and stabilizes the patient until the system is replaced.

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Correct Answer is C

Explanation

A. PaCO₂ of 45 mm Hgis incorrect because 45 mm Hg is at the upper limit of normal (normal 35–45 mm Hg). In early shock, clients often hyperventilate, causing a decreased PaCO₂. A value of 45 mm Hg alone does not specifically indicate irreversible shock.

B. Respirations 30/minis incorrect because tachypnea is a compensatory mechanism seen in the early (compensatory) stage of shock. The body attempts to improve oxygen delivery by increasing respiratory rate. This finding alone does not indicate irreversible shock.

C. Urine output 15 mL/hris correct because severely decreased urine output indicates significant renal hypoperfusion and possible acute kidney injury. In the irreversible (refractory) stage of shock, prolonged tissue hypoxia leads to organ failure. Oliguria (less than 30 mL/hr in adults) is a critical sign of worsening shock, and 15 mL/hr reflects severe compromise and progression toward multi-organ failure.

D. Blood pressure of 100 mm Hg systolicis incorrect because although this may be slightly low depending on baseline, it does not necessarily indicate irreversible shock. In early shock, blood pressure may remain near normal due to compensatory vasoconstriction. Profound, persistent hypotension despite interventions is more consistent with the irreversible stage.

A. 0.5 mL/dose B. 3 mL/dose C. 1.5 mL/dose D. 6 mL/dose

Correct Answer is C

Explanation

A. This option is incorrect, check rationale for option C.

B. This option is incorrect, check rationale for option C.

C. Step 1: Use the formula
Amount to administer (mL) = (Desired dose ÷ Dose available) × Volume available

Step 2: Insert known values
Desired dose = 15 mg
Dose available = 30 mg
Volume available = 3 mL

Amount to administer = (15 ÷ 30) × 3
Amount to administer = 0.5 × 3
Amount to administer = 1.5 mL

Step 3: Match the calculated volume to the options
1.5 mL → Option C

Final Answer: C. 1.5 mL/dose

D. This option is incorrect, check rationale for option C.

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A patient receiving treatment for a pneumothorax calls on the call light to tell you something is wrong with their chest tube. When you arrive to the room you note that the drainage system has fallen on its side and there is a large crack in the system. What is your next PRIORITY?

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who is in shock. Which of the following findings would indicate to the nurse that the client is entering an irreversible stage?

Correct Answer is C

Explanation

The doctor writes an order for a liquid oral medication. The order says to administer 15 mg by mouth every 4 hours as needed for sore throat. Pharmacy dispenses you with 30 mg/3ml. How many ml will you administer per dose?

Correct Answer is C

Explanation

The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? Select all that apply

The nurse is caring for a client with rib fractures and a pneumothorax who reports a pain score of 8/10. The nurse administered prescribed hydromorphone IV push and reassesses the client in 30 minutes. What data indicates that the treatment is effective?

The nurse is caring for an 87-year-old client who is admitted with manifestations of shock. Which of the following findings would the nurse identify as characteristics of older adults with shock? Select all that apply

Which client will the emergency nurse triage as the priority?

The nurse is admitting a client to the emergency department (ED) who was in a motor vehicle collision and has multiple traumatic injuries. Which of the following assumptions is a priority guiding principle for the nurse in this situation?