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When a chest tube is accidentally removed from a client, which of the following actions should the nurse NOT take first?
- A. Obtain a chest x-ray
- B. Apply sterile gauze to the insertion site
- C. Place tape around the insertion site
- D. Assess respiratory status
Correct Answer: B
Rationale: When a chest tube is accidentally removed, the priority action for the nurse is to immediately seal the insertion site with a gloved hand, a sterile occlusive dressing, or petroleum gauze to prevent air from entering the pleural space and causing a pneumothorax. Applying sterile gauze to the insertion site is not the correct initial action. The first step is to prevent respiratory compromise by ensuring the site is sealed. Therefore, the nurse should not apply sterile gauze to the insertion site first.
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A healthcare professional is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding?
- A. Impulse control difficulty
- B. Poor judgement
- C. Inability to recognize familiar objects
- D. Loss of depth perception
Correct Answer: C
Rationale: Patients who have experienced a left-hemispheric stroke may exhibit symptoms of agnosia, which is the inability to recognize familiar objects or people. This occurs due to damage to the right hemisphere of the brain, which is responsible for visual and spatial perception. Impulse control difficulty, poor judgment, and loss of depth perception are not typically associated with left-hemispheric strokes.
While caring for a client in a clinic, a healthcare professional learns that the client woke up not recognizing their partner, surroundings, has chills, and chest pain worsening upon inspiration. What should be the healthcare professional's priority action?
- A. Obtain baseline vital signs and oxygen saturation.
- B. Obtain a sputum culture.
- C. Obtain a complete history from the client.
- D. Provide a pneumococcal vaccine.
Correct Answer: A
Rationale: The priority action for the healthcare professional is to obtain the client's baseline vital signs and oxygen saturation. This will provide essential information on the client's current physiological status and help guide further assessment and intervention. Assessing the vital signs and oxygen saturation can help identify any immediate concerns like hypoxia or sepsis, which require prompt attention. While obtaining a complete history and considering a pneumococcal vaccine may be important in the overall care of the client, assessing the vital signs and oxygen saturation takes precedence to address the client's immediate physiological needs.
A healthcare professional is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should NOT be included in the plan of care?
- A. Encourage the client to cough every 2 hours.
- B. Check for continuous bubbling in the suction chamber.
- C. Strip the drainage tubing every 4 hours.
- D. Obtain a chest x-ray
Correct Answer: C
Rationale: Stripping the drainage tubing is an outdated practice and can cause complications. Encouraging the client to cough helps with lung expansion, checking for continuous bubbling ensures proper functioning of the chest tube system, and obtaining a chest x-ray helps to assess the position of the chest tube and re-expansion of the lung. Therefore, stripping the drainage tubing every 4 hours should not be included in the plan of care.
A healthcare provider is preparing to care for a client following chest tube placement. Which of the following items should NOT be available in the client's room?
- A. Oxygen
- B. Sterile water
- C. Enclosed hemostat clamps
- D. Indwelling urinary catheter
Correct Answer: D
Rationale: Following chest tube placement, an indwelling urinary catheter is not typically needed or relevant to the care provided. Chest tube placement is primarily concerned with managing pleural effusion or pneumothorax, and urinary catheterization is not directly related to this procedure. Oxygen, sterile water, and enclosed hemostat clamps are commonly used items in the care of a client with a chest tube in place, to ensure proper oxygenation, maintain drainage system integrity, and manage any bleeding that may occur. Therefore, the indwelling urinary catheter should not be available in the client's room following chest tube placement.
A client in the emergency department is experiencing an acute asthma attack. Which assessment indicates an improvement in respiratory status?
- A. SaO2 95%
- B. Wheezing
- C. Retraction of sternal muscles
- D. Premature ventricular complexes (PVC's)
Correct Answer: A
Rationale: An SaO2 of 95% indicates an improvement in the client's oxygen saturation, suggesting better respiratory status. In asthma exacerbation, a decrease in SaO2 levels would signal worsening respiratory distress. Wheezing, retraction of sternal muscles, and premature ventricular complexes are indicators of respiratory compromise and worsening respiratory status in acute asthma attacks. Monitoring SaO2 levels is crucial in assessing the effectiveness of interventions and guiding treatment decisions.