The nurse is caring for a client who underwent a right lobectomy for lung cancer 24 hours ago and has a single chest tube on the right side. Which intervention(s) should the nurse plan to implement? Select all that apply.

Monitor collection container and replace when full.

Encourage frequent use of the incentive spirometer.

Assess area around chest tube for subcutaneous emphysema.

Keep tubing loosely coiled below the level of the chest.

Verify air bubbling present in the water seal chamber.

Answer and Explanation

Correct Answer : A,B,C,D

A. Monitor collection container and replace when full: The nurse should monitor the collection container to ensure it doesn't become full, as this could cause backflow into the pleural cavity. Replacing it when full is essential to maintain proper drainage.

B. Encourage frequent use of the incentive spirometer: Using the incentive spirometer helps prevent atelectasis and pneumonia by promoting lung expansion. It is important for postoperative recovery to maintain good respiratory function.

C. Assess area around chest tube for subcutaneous emphysema: Subcutaneous emphysema can occur if air leaks into the tissues around the chest tube. The nurse should check for this condition as it could indicate complications like an air leak or pneumothorax.

D. Keep tubing loosely coiled below the level of the chest: The tubing should be positioned below the chest to facilitate gravity drainage. Keeping it loosely coiled ensures that fluid and air drain efficiently without backflow.

E. Verify air bubbling present in the water seal chamber: Continuous bubbling in the water seal chamber is not expected and may indicate an air leak. Intermittent bubbling may be normal if the lung is still re-expanding, but ongoing bubbling should be reported, not simply verified.

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Correct Answer is A

Explanation

A. The combination of cognitive impairment, physical injury, and restraints poses a high risk for complications such as infection, skin breakdown, and falls. Close monitoring and nursing interventions are critical to ensure safety, comfort, and appropriate care in this patient.

B. While this client may need some care for the electrolyte imbalance and nausea, this situation is more stable compared to the elderly client with Alzheimer's. The RN's role here would focus on managing the electrolyte disturbance and providing symptom relief.

C. Although this client is postoperative and may need some care, the RN's focus would primarily be on pain management and monitoring for infection or complications. However, the client’s condition is relatively stable compared to the elderly client with multiple risks.

D. This client is also stable and may require some ongoing monitoring for respiratory issues. However, the level of care needed is less intensive compared to a client with cognitive issues, restraints, and a recent fracture.

A. Do you want to recheck the digoxin level again tomorrow morning to see if we can restart it? I will keep the client on the monitor to assess for changes in heart rate. B. The results came back for the digoxin level. It is currently 2.2 ng/mL (2.8 nmol/L). The client's heart rate was 79 beats/minute. She is alert. There are no signs and symptoms of decreased perfusion at this time. C. I am holding the digoxin because the client's digoxin level is too high. D. The client is a 61- year-old female with heart failure. She started digoxin 3 days ago.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"D"},"D":{"answers":"A"}}

Explanation

Rationale:

Assessment: This describes the findings relevant to the current situation, such as the elevated digoxin level (2.2 ng/mL), the client’s heart rate (79 beats/minute), and the absence of symptoms such as decreased perfusion, indicating that the client is stable for now.
Background: Provides necessary patient details, such as age, diagnosis (heart failure), and the fact that the client has been on digoxin for three days, so the nurse provides a brief clinical history relevant to the current issue.
Recommendation: The nurse suggests rechecking the digoxin level the next day to assess if it has returned to the therapeutic range. Suggests an action to the healthcare provider (recheck digoxin level tomorrow) and indicates that the nurse will monitor the client closely for any changes.
Situation: The nurse is holding the digoxin due to the elevated level, which exceeds the therapeutic range. This introduces the immediate reason for the call, explaining the context of the patient's condition and recent treatment.

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The nurse is caring for a client who underwent a right lobectomy for lung cancer 24 hours ago and has a single chest tube on the right side. Which intervention(s) should the nurse plan to implement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses (RN) will be working that shift. In planning assignments, which client should receive the most care hours by a RN?

Correct Answer is A

Explanation

Exhibits The nurse calls the healthcare provider (HCP) to notify them that the digoxin level is above therapeutic range. Place the nurse statements in Situation, Background, Assessment, Recommendation (SBAR) format. Each column must have only one response selected.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"D"},"D":{"answers":"A"}}

Explanation

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