Which nursing intervention is a priority for a patient with a newly inserted chest tube?

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Question 1 of 5

Which nursing intervention is a priority for a patient with a newly inserted chest tube?

Correct Answer: B

Rationale: The correct answer is B: Monitor for continuous bubbling in the water-seal chamber. This is the priority intervention because continuous bubbling indicates an air leak, which can lead to a pneumothorax. By monitoring for bubbling, the nurse can detect and address the issue promptly. Clamping the chest tube during transport (choice A) is incorrect as it can lead to a tension pneumothorax. Encouraging coughing and deep breathing (choice C) is important for respiratory hygiene but not the priority. Keeping the drainage system at the patient's chest level (choice D) is crucial for proper drainage but does not address the immediate concern of detecting an air leak.

Question 2 of 5

A patient with asthma is prescribed a corticosteroid inhaler. What should the nurse include in the teaching?

Correct Answer: B

Rationale: The correct answer is B: Rinse your mouth after using the inhaler. Rinsing the mouth helps prevent oral thrush, a common side effect of corticosteroid inhalers. Choice A is incorrect because inhalers are not meant for acute attacks. Choice C is incorrect because corticosteroid inhalers are usually taken regularly, not necessarily before meals. Choice D is incorrect because spacers can improve the delivery of medication from inhalers.

Question 3 of 5

The nurse prepares to administer a flu vaccine to a patient. Which condition requires the nurse to consult the provider first?

Correct Answer: B

Rationale: The correct answer is B because the flu vaccine is typically grown in eggs, so individuals with an egg allergy may experience an allergic reaction. Consulting the provider is necessary to determine if an alternative vaccine or precaution is needed. Choices A, C, and D do not contraindicate the administration of the flu vaccine and do not require consultation before administration.

Question 4 of 5

The nurse discusses acute sinusitis management with a patient. Which statement indicates the need for further teaching?

Correct Answer: B

Rationale: The correct answer is B. Nasal decongestant sprays should not be used for more than 3 days due to the risk of rebound congestion. Choice A promotes hydration, which is beneficial. Choice C supports pain management. Choice D encourages monitoring for changes in nasal secretions, which is important for tracking progress. Long-term use of nasal decongestant sprays can worsen symptoms.

Question 5 of 5

A patient with pneumonia reports severe pleuritic chest pain. What is the nurse's priority action?

Correct Answer: A

Rationale: The correct answer is A: Administer prescribed pain medication. Severe pleuritic chest pain in a patient with pneumonia indicates inflammation of the pleura, which can be very distressing and require immediate relief. Administering pain medication will help alleviate the patient's discomfort, improve breathing, and enhance their overall well-being. Positioning the patient in high Fowler's (choice B) may help with breathing but does not address the immediate pain relief needed. Encouraging deep breathing exercises (choice C) may exacerbate the pain. Applying warm compresses to the chest (choice D) may provide some comfort but does not directly address the severe pain.

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