A nurse cares for a client who has a chest tube. When would...

A nurse cares for a client who has a chest tube. When would this client be at highest risk for developing a pneumothorax?

A. When the tube drainage increases and warms to the touch.
B. When the tube drainage decreases and becomes sanguineous.
C. When the client experiences pain at the insertion site.
D. When the tube becomes disconnected from the drainage system.

Correct Answer: D

Rationale: A disconnected chest tube allows air to enter the pleural space due to negative intrathoracic pressure, causing a pneumothorax. Warm drainage, sanguineous drainage, or pain at the insertion site do not directly increase pneumothorax risk.

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While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first?

A. Assess for drainage from the site.
B. Cover the insertion site with sterile gauze.
C. Contact the provider and obtain a suture kit.
D. Reinsert the tube using sterile technique.

Correct Answer: B

Rationale: Covering the insertion site with sterile gauze prevents air from entering the pleural space, which could cause a pneumothorax. Assessing drainage, contacting the provider, or reinserting the tube are secondary actions after securing the site to prevent complications.

A nurse cares for a client who is prescribed an intravenous prostacyclin agent. Which actions should the nurse take? (Select all that apply.)

A. Keep an intravenous line dedicated strictly to the infusion.
B. Teach the client that this medication increases pulmonary pressures.
C. Ensure that there is always a backup drug cassette available.
D. Start a large-bore peripheral intravenous line.
E. Use strict aseptic technique when using the drug delivery system.

Correct Answer: A,C,E

Rationale: Prostacyclin should be administered via a dedicated central venous catheter with strict aseptic technique to prevent infection. A backup cassette is essential due to risks of interruption. The medication decreases pulmonary pressures, and a central line, not peripheral, is used.

After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the client's understanding. Which statement indicates the client comprehends the teaching?

A. I will carry this medication with me at all times in case I need it.
B. I will take this medication when I start to experience an asthma attack.
C. I will take this medication every morning to help prevent an acute attack.
D. I will be weaned off this medication when I no longer need it.

Correct Answer: C

Rationale: Long-acting beta2 agonist medications are used to prevent asthma attacks due to their long-acting nature. The client should take this medication daily for best effect. It is not a rescue medication, so it does not need to be carried at all times or used during an attack. Clients are not typically weaned off this medication as it is likely a daily maintenance therapy.

A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that he no longer enjoys going out with his friends. How should the nurse respond?

A. There are a variety of support groups for people who have COPD.
B. I will ask your provider to prescribe an antianxiety agent.
C. Friends can be a good support system for clients with chronic disorders.
D. Encourage the client to participate in social activities.

Correct Answer: A

Rationale: Many clients with moderate to severe COPD become socially isolated due to embarrassment from frequent coughing and mucus production or fatigue. Suggesting a support group addresses this issue by connecting the client with others who share similar experiences. Antianxiety agents or encouraging social activities without addressing the underlying cause are less effective.

A nurse is teaching a client with cystic fibrosis (CF). Which statements should the nurse include in this client's teaching? (Select all that apply.)

A. Drink fluids with meals to stay hydrated.
B. Rest before meals to conserve energy.
C. Eat six small meals a day.
D. Eat high-fiber foods to promote gastric emptying.
E. Increase carbohydrate intake for energy.

Correct Answer: A,B,C

Rationale: Fluids should be avoided with meals to prevent bloating, resting before meals conserves energy, and six small meals reduce bloating. High-fiber foods can cause gas, worsening shortness of breath, and excessive carbohydrates increase carbon dioxide production, risking acidosis.