Your patient is breathing shallowly and seems irritable and restless. A nursing action that might help is to have him:

take a good nap

turn, cough and deep breathe

submit to a back rub

take some pain medication

Answer and Explanation

The Correct Answer is C

A. Take a good nap: While rest is important, shallow breathing and irritability may indicate inadequate ventilation, which won't improve solely with sleep.
B. Turn, cough, and deep breathe: This helps open the airways, promotes alveolar expansion, and clears secretions, which may improve oxygenation and reduce restlessness.
C. Submit to a back rub: Although comforting, it does not directly address shallow breathing or improve oxygenation.
D. Take some pain medication: Pain control can be essential, but this action is premature without assessing whether pain is the cause of shallow breathing.

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Correct Answer is D

Explanation

A. Clamp the chest tube and place the patient in high Fowler’s position: Clamping the tube may cause tension pneumothorax and should be done only with a specific prescription.
B. Immediately turn the patient to the side of the insertion site: This action does not address the source of constant bubbling.
C. Document findings: Bubbling in the suction chamber can be normal, but documenting without further assessment may overlook potential system issues.
D. Check for air leaks in the drainage system: Constant bubbling may indicate an air leak, which requires immediate assessment and correction.

A. Loop the tubing of the chest tube on the client's bed. B. Place the chest tube drainage system above the level of the client's heart. C. Strip the client's chest tube every 2 hrs. D. Tape the connections on the client's chest tube.

Correct Answer is D

Explanation

A. Loop the tubing of the chest tube on the client's bed: Looping can create kinks or blockages, impeding drainage and increasing the risk of complications.
B. Place the chest tube drainage system above the level of the client's heart: This would prevent gravity drainage, leading to fluid accumulation in the pleural space.
C. Strip the client's chest tube every 2 hrs: Stripping can create high negative pressure, damaging lung tissue.
D. Tape the connections on the client's chest tube: Securing all connections with tape helps maintain a closed system and prevents air leaks.

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Your patient is breathing shallowly and seems irritable and restless. A nursing action that might help is to have him:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for a patient with a water seal type chest drainage that is on low suction assesses that there is constant bubbling in the suction container. The nurse should:

Correct Answer is D

Explanation

A nurse is assisting with the care of a client who has a chest tube. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A patient requires suctioning via the nasotracheal route. In order to perform this procedure safely, the nurse should:

A nurse is reinforcing teaching with a client who is having difficulty using an incentive spirometer. Which of the following instructions should the nurse include in the teaching?

A nurse is reinforcing teaching with a newly licensed nurse about the manifestations of hypoxia. Which of the following findings should the nurse include in the teaching?

Older adults are more prone to respiratory problems because aging causes which change?

The nurse clarifies that the condition in which there is a decreased amount of oxygen in the blood is:

The nurse would determine that this patient is aware of how to use the incentive spirometer device properly when the patient:

The nurse is aware that changes occur in the respiratory system after the age of 70 that put the older adult more at risk for respiratory problems. These changes include: (Select all that apply.)

The nurse performing tracheostomy care will: