NCLEX-PN
Nclex PN Questions and Answers Questions
Extract:
Question 1 of 5
A nurse monitoring a client with a chest tube notes that there is no tidaling of fluid in the water seal chamber. After further assessment, the nurse suspects that the client's lung has reexpanded and notifies the healthcare provider. The healthcare provider verifies with the use of a chest x-ray that the lung has reexpanded, then calls the nurse to ask that the chest tube be removed. Which action should the nurse take first?
Correct Answer: C
Rationale: The correct action for the nurse to take first is to inform the healthcare provider that removal of a chest tube is not a nursing procedure. Actual removal of a chest tube is the duty of a healthcare provider. If the healthcare provider insists that the nurse remove the tube, the nurse must contact the nursing supervisor. Some agencies' policies and procedures may permit an advanced practice nurse to remove a chest tube, but there is no information in the question to indicate that the nurse is an advanced practice nurse.
Choice A is incorrect because the nurse should not proceed with removing the chest tube without proper authorization.
Choice B is incorrect as calling the nursing supervisor should come after clarifying with the healthcare provider.
Choice D is incorrect as the nurse should not begin the process of removing the chest tube without proper guidance and authorization.
Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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