The nurse is caring for a client with a chest tube. Which supplies should the nurse ensure are readily available at the client's bedside for emergencies?
Rolled gauze and sterile saline
Petrolatum-impregnated sterile occlusive dressing
Suction tubing and Yankauer suction tip
Non-adhesive dressing and tracheostomy tube
The Correct Answer is B
Choice A reason: Rolled gauze and sterile saline are used for general wound care but are inadequate for chest tube emergencies. If a tube dislodges, an occlusive dressing prevents air entry into the pleural space, avoiding pneumothorax, making this choice insufficient for emergency preparedness in chest tube management.
Choice B reason: A petrolatum-impregnated sterile occlusive dressing is critical for chest tube emergencies. If the tube dislodges, it seals the pleural space, preventing air entry and reducing pneumothorax risk. This ensures immediate response to maintain lung function, making it the priority supply for emergency preparedness.
Choice C reason: Suction tubing and Yankauer suction tip clear oral or airway secretions, not chest tube issues. They are irrelevant for emergencies like tube dislodgement, where sealing the pleural space prevents pneumothorax, making this choice inappropriate for chest tube emergency preparedness in this scenario.
Choice D reason: Non-adhesive dressings and tracheostomy tubes are for tracheostomy care, not chest tubes. They do not address emergencies like tube dislodgement, which require an occlusive dressing to prevent air entry, rendering this choice incorrect for chest tube emergency preparedness in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
No explanation
Correct Answer is ["A","D","E"]
Explanation
Choice A reason: Anxiety and restlessness indicate ineffective oxygen therapy, as they suggest persistent hypoxia or hypercapnia. The brain senses inadequate oxygenation, triggering a stress response, indicating the need for adjusted oxygen delivery or investigation into underlying respiratory issues, making this a sign of therapy failure.
Choice B reason: Pink, warm skin indicates adequate oxygenation and perfusion, suggesting effective oxygen therapy. Cyanosis or cool skin would signal hypoxia. This finding reflects successful correction of oxygen deficits, making it an incorrect choice for indicating ineffective therapy in this client with supplemental oxygen.
Choice C reason: A heart rate of 58 (bradycardia) is not a primary indicator of ineffective oxygen therapy. Severe hypoxia typically causes tachycardia, while bradycardia may reflect other issues like medication effects, not directly oxygen therapy failure, making it less relevant in this context.
Choice D reason: A respiratory rate of 36 (tachypnea) indicates ineffective oxygen therapy, as rapid breathing reflects the body’s attempt to compensate for hypoxia or hypercapnia. This suggests insufficient oxygen delivery, requiring adjustment of oxygen flow or evaluation for respiratory issues, marking therapy failure.
Choice E reason: Use of accessory muscles indicates ineffective oxygen therapy, reflecting increased work of breathing due to persistent hypoxia or airway obstruction. Muscles like the sternocleidomastoid are recruited when primary respiratory muscles fail to maintain adequate oxygenation, signaling the need for immediate intervention.
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