One 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 50 mLs of bloody drainage, and the nurse observes fluctuation in the water seal chamber. Which action should the nurse take?
Administer pain medication as prescribed.
Notify the healthcare provider immediately.
Reposition the patient to the unaffected side.
Document the findings and continue to monitor the drain.
The Correct Answer is A
A. Administering pain medication is the priority action in this scenario. The patient is experiencing significant post-surgical pain, which can impair their ability to breathe deeply and effectively. Addressing pain will improve comfort and facilitate better respiratory effort.
B. Notifying the healthcare provider immediately is not warranted based on the current findings. The amount of drainage (50 mL) is within expected limits for the first hour after surgery, and fluctuation in the water seal chamber indicates the chest tube is functioning properly.
C. Repositioning the patient to the unaffected side may help with comfort but is not the most appropriate action to address the pain or improve respiratory status in this situation.
D. Documenting the findings and continuing to monitor the drain is important but does not address the patient’s immediate need for pain relief.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Oxygen at 4L per minute is generally too high for clients with COPD. High oxygen concentrations can suppress their hypoxic drive, which is their primary mechanism for breathing.
B. Oxygen at 2L per minute is the appropriate starting rate for clients with COPD. This flow rate provides supplemental oxygen without significantly increasing the risk of suppressing the client’s respiratory drive.
C. Oxygen at 6L per minute is excessive for clients with COPD and can lead to complications such as hypercapnia or respiratory depression.
D. Oxygen at 8L per minute is not recommended for clients with COPD unless specifically ordered in a life-threatening situation, as it can suppress their respiratory drive and worsen their condition.
Correct Answer is B
Explanation
A. Rhonchi are low-pitched, coarse sounds heard during both inspiration and expiration. They are typically associated with mucus or secretions in the larger airways and do not match the description of high-pitched squeaking sounds.
B. Wheezes are high-pitched, continuous sounds heard primarily during expiration. They result from narrowed airways, which are characteristic of asthma. The description provided matches wheezes, making this the correct documentation.
C. Stridor is a high-pitched sound heard predominantly during inspiration and is associated with upper airway obstruction. It does not match the description of sounds heard during exhalation.
D. Crackles are discontinuous, popping sounds heard during inspiration and are associated with fluid in the alveoli or smaller airways. They do not match the high-pitched squeaking sounds described.
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