To safely transport a client with chest tube drainage to the x-ray department to assess the degree of lung re-expansion, the nurse would:
remove the chest tube and cover the incision site with a sterile petrolatum gauze.
disconnect the drainage system covering the catheter tip with sterile gauze.
send the client to x-ray with the chest tube clamped.
send the client to x-ray with the chest tube attached to the drainage system
The Correct Answer is D
A. Remove the chest tube and cover the incision site with a sterile petrolatum gauze: Removing the chest tube is not appropriate for transporting the patient to the x-ray department. The chest tube is essential for draining air, blood, or fluid from the pleural space and preventing complications like pneumothorax or fluid buildup. Removing it could cause harm and disrupt the treatment.
B. Disconnect the drainage system covering the catheter tip with sterile gauze: Disconnecting the drainage system is not recommended as it could cause the re-accumulation of air or fluid in the pleural space and compromise the patient's condition. The chest tube should remain connected to the drainage system to ensure continued drainage and prevent complications.
C. Send the client to x-ray with the chest tube clamped: Clamping a chest tube is not recommended unless specifically directed by a healthcare provider (such as during certain procedures or trials). Clamping can lead to dangerous complications, such as a tension pneumothorax, by preventing proper drainage of air or fluid. Therefore, the chest tube should not be clamped during transport.
D. Send the client to x-ray with the chest tube attached to the drainage system: This is the correct answer. The chest tube should remain attached to the drainage system during transport to ensure continuous drainage of air or fluid from the pleural space, which is vital for the patient's stability. The drainage system should be securely positioned to avoid kinks or disconnections, and the chest tube should remain open to prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B"]
Explanation
A. Increasing blood viscosity is not a goal in the care of a patient with acute myocardial infarction (MI). In fact, reducing blood viscosity by using anticoagulants or antiplatelets is typically part of the treatment to prevent clot formation.
B. Preventing complications, such as arrhythmias, heart failure, or recurrent infarction, is a key goal in the care of a patient after an acute MI.
C. Relieving chest pain is a priority goal in MI care, as it improves the patient's comfort and helps in reducing myocardial oxygen demand.
D. Increasing cardiac workload can worsen myocardial ischemia and damage. The goal is to reduce workload, not increase it, by using medications like beta-blockers and nitrates to decrease heart rate and blood pressure.
E.Reducing myocardial damage is essential, often achieved through interventions such as thrombolytic therapy, percutaneous coronary interventions (PCI), and medications to restore blood flow and limit infarction size.
Correct Answer is C
Explanation
A. Atorvastatin at bedtime to reduce my cholesterol levels.: is a statin used to lower cholesterol levels and reduce the risk of further cardiovascular events. It is commonly recommended to take statins in the evening because cholesterol synthesis occurs mostly at night. The client is following proper instructions here.
B. Metoprolol to decrease my heart's need for oxygen.: Metoprolol is a beta-blocker that reduces the heart's demand for oxygen by lowering the heart rate, blood pressure, and the force of contraction. This helps in reducing the risk of further complications after a myocardial infarction (MI).
C. Sublingual nitroglycerin each day to prevent chest pain.: This indicates the need for further education. Sublingual nitroglycerin is typically used as needed for acute chest pain or angina and should not be taken regularly each day for prevention. For long-term prevention, other medications like beta-blockers or calcium channel blockers are usually prescribed, not sublingual nitroglycerin. Taking nitroglycerin every day without chest pain could cause unnecessary side effects, such as hypotension or tolerance to the medication.
D. Clopidogrel to prevent clots from forming.: Clopidogrel is an antiplatelet medication that helps to prevent blood clots from forming by inhibiting platelet aggregation. It is often prescribed following a myocardial infarction to reduce the risk of further clot formation and to improve cardiovascular outcomes.
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