The drainage in the chest tube of a client with emphysema has changed from viscous green to clear watery fluid. Which action is best for the nurse to tak?
Schedule a portable chest x-ray per PRN protocol.
Maintain the current IV antibiotic schedule.
Obtain a specimen of the drainage for culture.
"Milk" the tube to remove any clots.
The Correct Answer is C
A. A chest x-ray can be useful to assess for complications or changes in lung status, such as pneumothorax, pleural effusion, or changes in lung volume. However, the change in drainage color from viscous green to clear watery fluid may not immediately warrant an x-ray unless there are additional clinical concerns or symptoms suggesting a need for imaging.
B. Continuing the IV antibiotic schedule is important if there is an ongoing infection that needs treatment. However, if the change in drainage is significant and suggests a potential change in the underlying condition or complication, it’s important to evaluate the cause of the change rather than solely relying on antibiotics.
C. Obtaining a specimen of the drainage for culture is a valuable action if there is concern about infection or if the drainage characteristics have changed unexpectedly. Clear, watery fluid could indicate the presence of serous fluid or a change in the nature of the drainage, potentially due to infection or resolution of an infection.
D. “Milking” or stripping the chest tube is not recommended as a routine practice because it can create negative pressure and potentially damage the pleural tissues or exacerbate issues. Additionally, the change in the drainage from viscous green to clear watery fluid does not necessarily indicate that clots are present or that tube milking would be helpful.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Monitoring intake and output can be important for overall fluid management, it is not the most urgent intervention for a client presenting with symptoms suggestive of a stroke or other acute neurological event. The immediate concern should be to evaluate and manage the neurological symptoms rather than focusing on urinary output at this stage.
B. Bilateral intermittent sequential pneumatic compression devices are used to prevent deep vein thrombosis (DVT) in immobile patients. This is not directly relevant to the acute neurological symptoms described and does not address the immediate need for evaluating the cause of the sudden headache and facial droop.
C. While aspirin may be used in some cases to prevent further clot formation in patients with certain types of strokes, administering it without a clear diagnosis and without ruling out contraindications could be harmful. The client needs immediate diagnostic evaluation to determine if a stroke or another condition is present before starting any medication like aspirin.
D. Obtaining a focused history is crucial in the context of sudden onset neurological symptoms. This includes assessing for recent bleeding, trauma, or the use of anticoagulants, which can help in diagnosing and managing conditions like stroke. Understanding the client's medication history and any recent bleeding events is important for guiding appropriate treatment and ensuring safe management.
Correct Answer is A
Explanation
A. The client's symptoms of headache, blurred vision, vertigo, and nausea, even without abnormal vital signs, are suggestive of potential neurological complications from a head injury, such as increased intracranial pressure (ICP). This requires immediate attention and evaluation.
B. While the client is experiencing discomfort, it is secondary to the potential neurological issue.
C. The client's nutritional status is a concern, but it is not the priority at this time, given the potential neurological implications of the client's symptoms.
D. While the client's anxiety is understandable, it is not the primary concern given the more immediate health risk.
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