What should Nurse Amanda check for if a client with a chest tube develops signs of tension pneumothorax?

Correct Answer: B

Rationale: Correct Answer: B - Kinked or obstructed chest tube. Rationale: 1. Tension pneumothorax is a life-threatening condition where air accumulates in the pleural space, causing lung collapse. 2. Signs include respiratory distress, chest pain, hypoxia, and tracheal deviation. 3. Nurse Amanda must check the chest tube for kinks or obstructions as it can prevent proper drainage and exacerbate the condition. 4. Infection of the lung (A) may be a concern but is not immediate in tension pneumothorax. 5. Excessive water in the water-seal chamber (C) may indicate a leak but is not directly related to tension pneumothorax. 6. Excessive chest tube drainage (D) may be expected initially, but if it suddenly stops, it could indicate kinking or obstruction.

Correct Answer: D

Rationale: The correct answer is D: Counselor. The nurse assumes the role of counselor when guiding a client in making healthcare decisions by providing emotional support, helping the client explore options, and facilitating informed decision-making. A leader typically involves taking charge or directing a group, which may not always be appropriate in this context. An advocate focuses on promoting the client's rights and best interests but may not necessarily provide the counseling aspect. A liaison acts as a link or intermediary between the client and other healthcare providers, which is different from providing direct counseling and support.

Correct Answer: D

Rationale: Correct Answer: D Rationale: 1. The cuff size should be appropriate to ensure accurate readings. 2. A cuff that is too small can result in falsely elevated readings. 3. A cuff that is too large can lead to falsely low readings. 4. Placing the cuff 1 cm above the brachial artery ensures proper placement for accurate measurements. Other Choices: A: The nurse should make sure that the cuff is deflated fully - Incorrect. The cuff should be inflated fully for accurate readings. B: then immediately start the second reading for the same client - Incorrect. It is important to wait a few minutes between readings to allow the blood vessels to recover. C: The nurse should release the valve carefully so that the pressure decreases at the rate of 2-3 mmHg per second - Incorrect. The pressure should be released at a steady rate, not specific to 2-3 mmHg per second.

Correct Answer: B

Rationale: The correct answer is B: Remove dead skin cells and debris. Wet-to-dry dressings help in debriding the wound by promoting the removal of dead tissue and debris when the dressing is changed. This process aids in creating a clean wound bed, which is essential for proper wound healing. The other choices are incorrect because wet-to-dry dressings are not primarily used to prevent wound infections (A), absorb blood and drainage (C), or protect the skin from injury (D). These functions may be achieved through other types of dressings or wound care methods.

Correct Answer: C

Rationale: Correct Answer: C Rationale: The client is experiencing signs of a transfusion reaction, likely due to a blood type incompatibility. Running normal saline at a keep-vein-open rate helps maintain the client's circulation and blood pressure while stopping the transfusion. This step is crucial to prevent further complications and stabilize the client's condition. Summary of Other Choices: A: Removing the IV line may worsen the situation as it can lead to air embolism or abrupt changes in fluid balance. B: Running a solution of 5% dextrose in water is not the appropriate intervention for a transfusion reaction and does not address the underlying issue. D: Obtaining a culture of the catheter tip is not a priority in this acute situation and does not directly address the client's immediate needs.