When caring for a client with a chest tube, the nurse would avoid the practice

Encouraging the client to cough and deep breathe every two hours.

Striping the chest tube to dislodge any blood clots

Assessing the client's respiratory status frequently

Monitoring skin for subcutaneous emphysema

Answer and Explanation

The Correct Answer is B

A) Encouraging the client to cough and deep breathe every two hours:
Encouraging the client to cough and deep breathe is an important nursing intervention for clients with a chest tube. This helps promote lung expansion, prevent atelectasis, and improve respiratory function. It also helps to clear secretions that may accumulate in the lungs. Therefore, this practice is appropriate and beneficial for the client.

B) Stripping the chest tube to dislodge any blood clots:
Stripping the chest tube, which involves forcibly pulling or pinching the tubing to remove clots, is an unsafe and outdated practice. It can create a dangerous increase in intrathoracic pressure, which may lead to tension pneumothorax, as well as injury to the lung tissue. Instead, the nurse should focus on gently milking the chest tube if necessary (if prescribed by the healthcare provider) or ensure that any blood clots are properly managed by the physician. Stripping or clamping the tube without proper indications is contraindicated.

C) Assessing the client's respiratory status frequently:
Frequent assessment of the client's respiratory status is crucial when managing a patient with a chest tube. The nurse should monitor for signs of respiratory distress, changes in breath sounds, oxygen saturation, and any signs of complications such as pneumothorax or hemothorax. Regular respiratory assessment helps in early detection of issues and provides the data necessary to manage the client's care effectively.

D) Monitoring skin for subcutaneous emphysema:
Monitoring for subcutaneous emphysema is a vital part of nursing care for a client with a chest tube. Subcutaneous emphysema occurs when air escapes from the pleural space into the tissues under the skin, and can be a sign of a pneumothorax or a complication related to the chest tube. It is important to detect this early so appropriate intervention can be made to prevent further complications.

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Correct Answer is C

Explanation

A. "I will report any unusual movements or behaviors to my healthcare provider."
This statement is correct and indicates that the client understands the potential side effects of levodopa/carbidopa. The medication can cause dyskinesia (uncontrolled movements) and other behavioral changes, so the client should report these symptoms to their healthcare provider for possible adjustment of the treatment plan.

B. "I may experience nausea while taking this medication."
This is also correct. Nausea is a common side effect of levodopa/carbidopa, especially when starting the medication. Taking it with food may help reduce this side effect, but some clients may still experience nausea.

C. "I will take this medication with a high-protein meal."
This statement is incorrect. Levodopa is absorbed best on an empty stomach or with a low-protein meal. Protein can interfere with the absorption of levodopa because amino acids (found in proteins) compete with levodopa for absorption across the blood-brain barrier. Therefore, it's recommended that levodopa/carbidopa be taken either 30 minutes before or 1 hour after meals, especially those high in protein.

D. "I will avoid sudden changes in position to prevent dizziness or falls."
This statement is correct. Levodopa/carbidopa can cause orthostatic hypotension (a sudden drop in blood pressure when standing up), which increases the risk of dizziness and falls. The client should be advised to change positions slowly and use support when rising from a sitting or lying position to avoid injury.

A. Schedule activities late in day and in the evening B. Provide supplemental oxygen when fatigued C. Teach the importance of hot showers to help relax D. Have the client prioritize activities for the day

Correct Answer is D

Explanation

A. Schedule activities late in the day and in the evening:

Scheduling activities late in the day is not an ideal approach for managing fatigue in clients with MS. Fatigue typically worsens as the day progresses, and clients with MS often experience more energy depletion in the late afternoon and evening. Therefore, the best time to schedule demanding activities is earlier in the day when the client may have more energy. Scheduling strenuous tasks late in the day may exacerbate fatigue and lead to physical and emotional exhaustion.

B. Provide supplemental oxygen when fatigued:

While oxygen therapy is appropriate for clients with respiratory issues or other conditions that affect oxygenation, it is not the most relevant intervention for addressing fatigue in MS. Fatigue in MS is primarily caused by neurological factors, muscle weakness, or impaired mobility, not by a lack of oxygen. The priority for MS-related fatigue is managing energy levels through activity planning and rest, not providing supplemental oxygen unless there is a specific indication of respiratory distress or hypoxia.

C. Teach the importance of hot showers to help relax:

Hot showers may help some individuals relax, but they are not the best intervention for managing fatigue in MS. In fact, heat can sometimes worsen symptoms in clients with MS, a phenomenon known as Uhthoff’s phenomenon, where heat increases neurological symptoms such as muscle weakness, fatigue, or visual disturbances. It is important to educate clients to avoid overheating, which could exacerbate fatigue or other symptoms. Instead, clients should focus on rest, energy conservation, and temperature regulation.

D. Have the client prioritize activities for the day: Fatigue is a common and debilitating symptom in clients with multiple sclerosis (MS), and it can significantly affect their daily functioning. One of the most effective interventions for managing fatigue in MS is to encourage the client to prioritize activities and manage their energy levels throughout the day. By scheduling the most important or demanding tasks earlier in the day when energy levels tend to be higher, clients can conserve energy for essential activities. Additionally, teaching clients to break tasks into smaller, manageable steps and incorporating frequent rest periods can help minimize fatigue and prevent overexertion. Prioritizing activities ensures that the client is not overwhelmed and can still maintain independence while managing their symptoms effectively.

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When caring for a client with a chest tube, the nurse would avoid the practice

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who will be taking levodopa/carbidopa for Parkinson's disease. Which of the following statements by the client indicates a need for further teaching?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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