The nurse has assisted a health care provider (HCP) with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level (tidaling) in the water seal chamber after the tube is inserted. Based on this assessment finding, which action is most appropriate?
Inform the HCP.
Continue to monitor the client.
Reinforce the occlusive dressing.
Encourage the client to deep breathe
The Correct Answer is B
A. Inform the HCP: Notifying the healthcare provider is unnecessary in this case, as tidaling in the water seal chamber is an expected and normal finding. It indicates that the chest tube is patent and responding to changes in thoracic pressure during respiration.
B. Continue to monitor the client: Tidaling reflects normal movement of air and fluid in response to respiration, suggesting the chest tube is functioning correctly. The most appropriate action is to continue monitoring the client.
C. Reinforce the occlusive dressing: There is no indication that the dressing is loose or compromised. Without evidence of air leak or tube displacement, reinforcing the dressing is not necessary at this point.
D. Encourage the client to deep breathe: While deep breathing is important for lung expansion and preventing complications like atelectasis, it is not specifically indicated in response to the observation of tidaling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Vitamin K:Vitamin K is the antidote for warfarin overdose. Warfarin inhibits vitamin K-dependent clotting factors, and administering vitamin K reverses this effect by promoting the synthesis of clotting factors to control bleeding.
B. Magnesium sulfate:Magnesium sulfate is used to treat conditions such as torsades de pointes and eclampsia but has no role in reversing the anticoagulant effects of warfarin. It does not impact coagulation pathways or vitamin K levels.
C. Flumazenil:Flumazenil is an antidote for benzodiazepine overdose. It acts by antagonizing the effects of drugs like diazepam and lorazepam but has no effect on warfarin or anticoagulation reversal.
D. Protamine sulfate:Protamine sulfate is the antidote for heparin and low-molecular-weight heparin overdose, not warfarin. It neutralizes heparin's anticoagulant properties but does not interact with vitamin K or affect warfarin action.
Correct Answer is A
Explanation
A. Bacteria:Antibiotics are specifically used to treat bacterial infections. In the case of pharyngitis, antibiotics are appropriate if the infection is caused by Streptococcus pyogenes(Group A strep), which can be confirmed via rapid strep test or throat culture.
B. A fungal infection:Fungal infections are treated with antifungal medications, not antibiotics. Pharyngitis caused by fungi (e.g., Candida) is rare and requires different pharmacologic management.
C. A virus:Viral pharyngitis is the most common cause of sore throat and does not respond to antibiotics. Treating viral infections with antibiotics contributes to antimicrobial resistance and unnecessary side effects.
D. Protozoa:Protozoal infections typically affect the gastrointestinal or urogenital tract and are not a cause of pharyngitis. They are treated with antiparasitic agents, not antibiotics.
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