A patient with a chest tube accidentally pulls the tube out while turning in bed.
What should the nurse do first?
Place an occlusive dressing over the site.
Call the health care provider immediately.
Assist the patient into high-Fowler's position.
Quickly reinsert the chest tube using sterile technique.
The Correct Answer is A
Choice A rationale
When a chest tube is accidentally removed, the first priority is to prevent air from entering the pleural space. An occlusive dressing, secured on three sides, acts as a one-way valve, allowing air to escape during exhalation but preventing air from being sucked back in during inhalation. This prevents the development of a tension pneumothorax.
Choice B rationale
While the health care provider must be notified, it is not the first action. The immediate priority is to address the life-threatening risk of a tension pneumothorax. Securing the site with an occlusive dressing takes precedence over contacting the physician.
Choice C rationale
The patient's position is not the initial priority. The immediate and life-saving intervention is to cover the open wound to prevent air from entering the chest cavity, which can lead to a pneumothorax. Positioning the patient is a subsequent action.
Choice D rationale
Reinserting the chest tube is an invasive procedure that must be performed by a qualified health care provider under sterile conditions. A nurse should never attempt to reinsert a chest tube, as this poses a significant risk of infection and injury to the patient. *.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2600"]
Explanation
The patient has an order for Percocet 2 tabs qh prn for pain. Based on the label below, if the patient takes 2 tabs every 6 hours, how much acetaminophen will the patient take in 24 hours?.
Step 1: Calculate the amount of acetaminophen per dose. 2 tabs × 325 mg/tab = 650 mg.
Step 2: Determine the number of doses in 24 hours. 24 hours ÷ 6 hours = 4 doses.
Step 3: Calculate the total amount of acetaminophen in 24 hours. 650 mg/dose × 4 doses = 2600 mg. The patient will take 2600 mg of acetaminophen in 24 hours.
Correct Answer is A
Explanation
Choice A rationale
Harsh soaps are alkaline substances that disrupt the skin's natural acidic mantle and lipid barrier. This breakdown of the stratum corneum allows irritants to penetrate more easily, leading to a direct inflammatory response in the keratinocytes and resulting in the characteristic rash and inflammation of irritant contact dermatitis.
Choice B rationale
Non-latex gloves are designed to be hypoallergenic and are typically used to prevent allergic reactions, a different type of contact dermatitis. They are generally considered less irritating than latex gloves for individuals with latex allergies and are unlikely to be a primary cause of irritant contact dermatitis.
Choice C rationale
Warm water is generally not considered an irritant. While prolonged exposure to hot water can strip the skin of its natural oils, warm water used for a short duration is not a typical cause of irritant contact dermatitis unless the individual has a pre-existing skin barrier dysfunction.
Choice D rationale
Vegetable oils are generally considered emollients, meaning they help to moisturize and protect the skin barrier. They are typically used in skincare products for their soothing properties and are very unlikely to cause irritant contact dermatitis unless the individual has a specific allergy to a component. *.
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