An hour after a left thoracotomy, a patient reports incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage. Which action would the nurse take?
Turn and reposition the patient.
Assist the patient with incentive spirometry.
Clamp the chest tube in two places.
Administer prescribed morphine.
The Correct Answer is D
Choice A reason: Repositioning may ease discomfort but won’t address severe pain (7/10) or reduced breath sounds post-thoracotomy. It risks dislodging tubes and doesn’t improve atelectasis or bleeding, lacking urgency for this acute scenario.
Choice B reason: Incentive spirometry prevents atelectasis, but pain limits participation. Decreased breath sounds suggest collapse, yet without pain control, this intervention is ineffective, delaying relief and lung expansion needed post-surgery.
Choice C reason: Clamping a chest tube risks tension pneumothorax by trapping air or blood, worsening breathing. With 100 mL drainage, it’s functioning; clamping is contraindicated unless ordered, making it dangerous here.
Choice D reason: Morphine reduces severe pain (7/10), enabling deeper breathing to reverse atelectasis. It addresses the primary barrier to recovery post-thoracotomy, improving ventilation and comfort, aligning with acute pain management protocols.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Mantoux induration of 10 mm indicates TB exposure, not active infection status. It’s a diagnostic tool, not a marker for contagiousness, so it doesn’t guide discontinuation of airborne precautions in treatment.
Choice B reason: Six months of TB meds suggests treatment progress, but contagiousness persists until sputum clears. Duration alone isn’t enough; microbiologic evidence is required to lift precautions, per infection control standards.
Choice C reason: Negative sputum smears for acid-fast bacilli (three consecutive) confirm non-infectiousness in TB. This microbiological clearance allows discontinuation of airborne precautions, as the patient no longer spreads viable bacteria via droplets.
Choice D reason: Clear x-ray (no infiltrates) shows healing, but sputum can remain infectious. Radiologic improvement lags behind contagiousness, so negative smears, not imaging, determine when precautions can safely end.
Correct Answer is A
Explanation
Choice A reason: Hospitalized patients often have immobility, surgery, or illness, increasing VTE risk via stasis, vessel injury, and hypercoagulability (Virchow’s triad). Studies show up to 60% of VTE cases occur in this setting, confirming the statement.
Choice B reason: False implies low VTE risk in hospitals, contradicting evidence. Inactivity and acute conditions elevate risk significantly, with prophylaxis standard in guidelines, as immobility alone triples clot formation likelihood.
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