The nurse prepares to assist the health care provider with the removal of a patient's chest tube.
Which priority instruction should the nurse provide to the patient immediately before removal?

Breathe in twice, then breathe out slowly with pursed lips.

Lie flat and breathe deeply so you won't feel pain.

Take a deep breath, hold it in, and bear down.

Inhale and exhale very rapidly until the tube is out.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Pursed-lip breathing is a technique used to slow down the breathing rate and facilitate a more complete exhalation, primarily beneficial for patients with obstructive lung diseases like COPD. It does not provide the positive intrathoracic pressure necessary to prevent air from entering the pleural space during a chest tube removal.

Choice B rationale

Lying flat and breathing deeply does not create the necessary positive pressure within the pleural cavity. This action would not prevent air from being sucked into the chest cavity, leading to a potential pneumothorax. The patient needs to increase intrathoracic pressure to seal the site.

Choice C rationale

The Valsalva maneuver, which involves taking a deep breath, holding it, and bearing down, increases intrathoracic pressure. This positive pressure helps to prevent air from rushing back into the pleural space when the chest tube is removed, thus minimizing the risk of a tension pneumothorax.

Choice D rationale

Rapid breathing, or hyperventilation, would decrease intrathoracic pressure and could potentially cause more air to be drawn into the pleural space upon removal of the chest tube. This action could lead to a tension pneumothorax. *.

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Correct Answer is ["A","C","D"]

Explanation

Choice A rationale

Burn injuries, especially those affecting the face, neck, and chest, significantly increase the risk of smoke inhalation and airway edema. Administering oxygen is crucial to counteract potential hypoxia resulting from impaired gas exchange in the lungs, carbon monoxide poisoning, and cellular anoxia. The goal is to maintain adequate tissue oxygenation and prevent respiratory failure, which is a leading cause of mortality in burn victims.

Choice B rationale

Fluid restriction is contraindicated in burn patients because they experience massive fluid shifts from the intravascular space into the interstitial spaces due to increased capillary permeability caused by the inflammatory response. This leads to hypovolemia and burn shock. Aggressive fluid resuscitation is necessary to maintain adequate circulating blood volume, tissue perfusion, and kidney function, preventing multi-organ system failure.

Choice C rationale

Assessing for airway patency is the absolute priority in a patient with burns to the face, neck, and chest. The heat and smoke can cause immediate laryngeal edema and subsequent upper airway obstruction, which can be life-threatening. The nurse must continuously monitor for signs such as stridor, hoarseness, and dyspnea, and prepare for potential intubation to secure the airway.

Choice D rationale

Elevating the extremities is a vital intervention for burn patients without fractures. The purpose of elevation is to reduce edema formation by promoting venous return and decreasing hydrostatic pressure in the burned limbs. This helps to maintain circulation, minimize tissue damage, and reduce pain. Edema is a major complication of burns due to the inflammatory response and increased capillary permeability.

Choice E rationale

Placing a cooling blanket on a burn patient is inappropriate and can be harmful. While cooling the burn area itself can decrease the inflammatory response, excessive cooling of the entire body, especially a large surface area, can lead to systemic hypothermia. Hypothermia impairs coagulation, decreases cardiac output, and can increase the risk of infection, all of which are detrimental to a burn patient.

A. The nurse is aware the hypotension could be a sign of which known complication that is associated with poor outcomes from pneumothorax? B. Bundle branch block. C. Deep vein thrombosis. D. Decreased cardiac output.

Correct Answer is C

Explanation

Choice C rationale

Hypotension in a patient with a pneumothorax, especially a tension pneumothorax, is a significant indicator of decreased cardiac output. The accumulation of air in the pleural space increases intrathoracic pressure, which compresses the vena cava and the heart, impairing venous return to the right side of the heart. This reduces preload, leading to a profound decrease in stroke volume and cardiac output, resulting in hypotension and obstructive shock.

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The nurse prepares to assist the health care provider with the removal of a patient's chest tube. Which priority instruction should the nurse provide to the patient immediately before removal?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is brought to the emergency department with partial thickness burns to their face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this patient?

Correct Answer is ["A","C","D"]

Explanation

A nurse is caring for a patient who has a pneumothorax and whose vitals show low blood pressure.

Correct Answer is C

Explanation

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The nurse prepares to assist the health care provider with the removal of a patient's chest tube.
Which priority instruction should the nurse provide to the patient immediately before removal?