Which intervention should the nurse include in the plan of care (POC) for a client who has a chest tube due to a hemothorax?

Keep the arm and shoulder of the affected side immobile at all times.

Maintain the chest tube drainage system slightly above the chest level.

Ensure that there is no fluctuation in the water-seal chamber.

Encourage the client to breathe deeply and cough at frequent intervals.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Keep the arm and shoulder of the affected side immobile at all times: Immobilization is not recommended. Early mobilization and gentle range-of-motion exercises help prevent stiffness, maintain circulation, and reduce the risk of complications like frozen shoulder.

B. Maintain the chest tube drainage system slightly above the chest level: The drainage system must be kept below the level of the chest to allow gravity drainage of blood and prevent backflow into the pleural space. Elevating it above chest level would be unsafe.

C. Ensure that there is no fluctuation in the water-seal chamber: Fluctuation (tidaling) in the water-seal chamber is expected and reflects normal intrathoracic pressure changes during respiration. Absence of fluctuation may indicate tube obstruction or lung re-expansion, which requires assessment.

D. Encourage the client to breathe deeply and cough at frequent intervals: Deep breathing and coughing prevent atelectasis, promote lung re-expansion, and help maintain adequate oxygenation after hemothorax. This is an essential nursing intervention for chest tube care.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:
A. Recommend hours for visitation: Limiting visitation can reduce stress, but it does not directly prevent life-threatening complications in mechanically ventilated clients. While helpful for comfort, it is not the priority intervention.

B. Use antiseptic solution with oral care: Oral care with antiseptic solution reduces bacterial colonization in the oropharynx, lowering the risk of ventilator-associated pneumonia (VAP), a common and serious complication in intubated clients. This intervention directly impacts morbidity and mortality, making it the most important nursing action.

C. Teach communication board use: Supporting communication promotes client autonomy and reduces frustration, but it does not prevent critical complications associated with ARDS or mechanical ventilation. It is important but secondary to infection prevention.

D. Promote uninterrupted periods of sleep: Sleep promotion supports recovery and reduces stress, yet it does not directly address high-risk complications such as VAP in mechanically ventilated clients. While beneficial, it is not the priority.

Correct Answer is ["20"]

Explanation

Calculation:

Identify the IV concentration and flow rate

IV Concentration: 100 mg in 500 mL: 100,000 mcg in 500 mL

Flow Rate: 6 mL/hr

Calculate the amount of drug infused per hour

Drug per hour (mcg/hr) = (Total Drug ÷ Total Volume) × Flow Rate

Drug per hour = (100,000 ÷ 500) × 6

Drug per hour = 200 × 6 = 1,200 mcg/hr

Convert mcg/hr to mcg/min

Drug per minute = 1,200 ÷ 60 = 20 mcg/min

= 20 mcg/min

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which intervention should the nurse include in the plan of care (POC) for a client who has a chest tube due to a hemothorax?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the intensive care unit (ICU) with sepsis and acute respiratory distress syndrome (ARDS). The client is orally intubated and mechanically ventilated. Which intervention is most important for the nurse to include in the client's plan of care (POC)?

Correct Answer is B

Explanation

A client is receiving an infusion of nitroglycerin 100 mg in 500 mL DW at 6 mL/hour. How many mcg/minute of nitroglycerin is infusing? (Enter numeric value only.)

Correct Answer is ["20"]

Explanation

The nurse is admitting a postoperative surgical client to the intensive care unit (ICU) and a ventilator is prescribed. While anticipating potential complications, which equipment should the nurse place at the client's bedside?

A client who experiences multiple traumatic injuries begins to ooze blood from an injection site. Which additional finding should the nurse identify that supports an early indication of disseminated intravascular coagulation (DIC)?

An adult female client presents to the emergency department (ED) reporting epigastric discomfort. The client reports shortness of breath and fatigue for the past two days. Which action should the nurse implement first?

The nurse is preparing to start an IV infusion of 1,000 mL of 0.9% sodium chloride with 30 mEq of potassium chloride for a client with diabetic ketoacidosis (DKA). Before implementing the prescription, which assessment finding is most important for the nurse to obtain?

Patient Data Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

A client's telemetry monitor indicates the sudden onset of ventricular fibrillation (VF). Which assessment finding should the nurse anticipate?