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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Vitamin supplements for high-risk pregnant women: Primary prevention aims to prevent disease before it occurs. Providing supplements like folic acid helps reduce the risk of neural tube defects and promotes maternal-fetal health.
B. Lead screening for children in low-income housing: This is secondary prevention, as it involves early detection of a problem to allow for prompt intervention and reduce complications.
C. Regional relocation center for earthquake victims: This is a tertiary prevention or disaster response measure, aimed at managing the aftermath of an event rather than preventing it.
D. Case management and screening for clients with HIV: This is secondary and tertiary prevention focused on managing an existing condition and minimizing progression or complications.
Correct Answer is C
Explanation
Rationale:
A. Clarify that all STIs are transmitted through sexual intercourse: Not all STIs are exclusively transmitted through intercourse; some can spread through oral-genital contact, skin-to-skin contact, or shared needles.
B. Emphasize that using safe sex practices removes the risk of STIs: Safe sex practices reduce the risk of STIs but do not completely eliminate it. Barrier methods like condoms lower transmission rates, but there is still a residual risk with skin-to-skin infections.
C. Explain that reinfections occur from sex with untreated partners: Clients treated for syphilis remain at risk of reinfection if their sexual partners are not also treated. Reinforcing this promotes partner notification and comprehensive treatment to stop the infection cycle.
D. Provide counseling that most contraceptives protect against infection: Most contraceptives, such as birth control pills, IUDs, or implants, prevent pregnancy but offer no protection against STIs. Only barrier methods like condoms can help prevent transmission.
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