While transferring a client with a chest tube from the bed to a stretcher, the chest tube becomes disconnected from the water- seal drainage container. The nurse immediately immerses the end of the tube in a container of sterile water. Which action should the nurse implement next?

Prepare a new water-seal system and reattach the chest tube.

Clamp the chest tube and maintain its distal end in the water.

Apply pressure to the chest tube site using a petroleum gauze.

Begin manual ventilation while returning the client to the bed.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Prepare a new water-seal system and reattach the chest tube: After temporarily placing the disconnected tube in sterile water to prevent air entry, the priority is to re-establish a closed drainage system to maintain negative intrathoracic pressure and prevent complications like tension pneumothorax.

B. Clamp the chest tube and maintain its distal end in the water: Clamping a chest tube can increase the risk of tension pneumothorax by trapping air inside the pleural cavity. It should only be done momentarily and under specific circumstances.

C. Apply pressure to the chest tube site using a petroleum gauze: This is appropriate if the chest tube becomes dislodged from the insertion site, not if it's disconnected from the drainage system. The insertion site remains intact in this case.

D. Begin manual ventilation while returning the client to the bed: There is no indication of respiratory distress or collapse requiring manual ventilation. The immediate need is to restore the chest tube drainage system.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:

A. Prevent injury: In CKD, high phosphate and low calcium levels contribute to bone demineralization, increasing fracture risk. Hypocalcemia can also cause muscle cramps and tetany, making fall prevention and safety a priority.

B. Prevent infection: While infection is a general concern in CKD, these specific lab findings do not indicate immunosuppression. The primary issue here relates to bone health and calcium-phosphate imbalance, not immune function.

C. Protect skin integrity: Skin care is important in CKD, especially with pruritus, but it is not the direct consequence of calcium-phosphate imbalance. The immediate risk related to these values is musculoskeletal, not dermatologic.

D. Manage fluid volume: Fluid volume control is essential in CKD but unrelated to phosphate-calcium shifts. These labs reflect mineral and bone metabolism disturbances, not volume overload or deficit.

A. Watery diarrhea. B. Heart burn. C. Confusion. D. Hematuria.

Correct Answer is C

Explanation

Rationale:

A. Watery diarrhea: While a known side effect of colchicine toxicity, it is typically an early sign. It requires follow-up but is not the most urgent compared to neurological changes.

B. Heartburn: Esophageal irritation is a possible reaction due to colchicine's GI side effects, but this symptom is not immediately life-threatening.

C. Confusion: Neurological changes such as confusion may indicate severe colchicine toxicity or systemic complications like renal failure or CNS involvement, and warrant immediate evaluation.

D. Hematuria: Although significant in a patient with a history of kidney stones, hematuria is not the most urgent sign unless accompanied by flank pain, fever, or decreased output.

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

While transferring a client with a chest tube from the bed to a stretcher, the chest tube becomes disconnected from the water- seal drainage container. The nurse immediately immerses the end of the tube in a container of sterile water. Which action should the nurse implement next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In caring for a client with chronic kidney disease (CKD), the nurse notes that the client's serum phosphate level is elevated, with a converse decrease in serum calcium. Which nursing care goal is a priority, based on these laboratory findings?

Correct Answer is A

Explanation

A client who has been taking colchicine calls the clinic with reports of an acute gout attack of the right great toe. The client has a history of kidney stones and esophageal reflux. Which finding warrants immediate intervention by the nurse?

Correct Answer is C

Explanation

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which activity should the nurse delegate to the UAP?

The first paddle has been placed on the chest of a client who needs defibrillation. Where should the nurse place the second paddle? (Mark the location where the second paddle should be placed on the image)

A group of nurses implement a pilot study to evaluate a proposed evidence-based change to providing client care. Evaluation indicates successful outcomes and the nurses want to integrate the change throughout the facility. Which actions should be taken? Select all that apply.

A client who has type 2 diabetes mellitus is admitted to the intensive care unit with third degree burns over 20% of the body. To decrease the client's risk of developing hyperosmolar hyperglycemic syndrome (HHS), which intervention(s) should the nurse implement? Select all that apply.

Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain?