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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Rationale: Stripping the drainage tubing is an outdated practice and can cause complications.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.
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A healthcare provider is caring for a client following a thoracentesis. Which of the following manifestations should the healthcare provider NOT recognize as risks for complications?
- A. Dyspnea
- B. Localized bloody drainage on the dressing
- C. Fever
- D. Hypotension
Correct Answer: B
Rationale: After a thoracentesis, some expected complications include dyspnea, fever, and hypotension. Localized bloody drainage on the dressing is a common and expected finding post-thoracentesis due to the procedure's nature of puncturing the chest wall. Therefore, the healthcare provider should not consider this finding as a risk for complications.
A healthcare professional is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the professional recognize?
- A. Confusion
- B. Pale skin
- C. Bradycardia
- D. Hypotension
Correct Answer: B
Rationale: Pale skin is an early manifestation of hypoxemia due to decreased oxygenation of the blood. The skin may appear pale as the body redirects blood flow to vital organs in response to low oxygen levels. Confusion, bradycardia, and hypotension may occur as hypoxemia worsens, but pale skin is one of the initial signs that healthcare professionals should recognize when assessing a client experiencing respiratory distress.
During the removal of a chest tube, what should the nurse instruct the client to do?
- A. Lie on their left side.
- B. Use the incentive spirometer.
- C. Cough at regular intervals.
- D. Perform the Valsalva maneuver.
Correct Answer: D
Rationale: During the removal of a chest tube, instructing the client to perform the Valsalva maneuver is essential. This maneuver involves holding the breath and bearing down, which helps prevent air from entering the pleural space during tube removal, reducing the risk of pneumothorax. Instructing the client to lie on their left side, use the incentive spirometer, or cough at regular intervals is not appropriate during the chest tube removal process.
A client is being educated by a healthcare provider on the purpose of taking a bronchodilator. Which of the following client statements indicates an understanding of the teaching?
- A. ''This medication can decrease my immune response.''
- B. ''I take this medication to prevent asthma attacks.''
- C. ''I need to take this medication with food.''
- D. ''This medication has a slow onset to treat my symptoms.''
Correct Answer: B
Rationale: The correct answer is, 'I take this medication to prevent asthma attacks.' Bronchodilators are commonly used to relieve bronchospasm in conditions such as asthma. This medication helps to dilate the airways, making it easier to breathe and preventing asthma attacks. The other options are incorrect: option A is inaccurate as bronchodilators do not decrease immune responses, option C is incorrect as bronchodilators are typically taken on an empty stomach for better absorption, and option D is false as bronchodilators have a rapid onset to provide quick relief of symptoms.
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.