Chest tubes
Chest tubes ( 15 Questions)
Administering diuretics to reduce fluid accumulation is incorrect. Severe dyspnea, absent breath sounds, and jugular venous distension indicate a potential tension pneumothorax or hemothorax, which requires prompt action, and diuretics would not address the underlying issue.
Preparing for needle decompression or chest tube insertion is the appropriate nursing action. The client's symptoms of severe dyspnea, absent breath sounds, jugular venous distension, and increased intrathoracic pressure suggest a possible tension pneumothorax or hemothorax. Immediate decompression with a large-bore needle or insertion of a chest tube is necessary to relieve pressure and restore lung function.
Positioning the client in a Trendelenburg position to facilitate breathing is incorrect. In the case of increased intrathoracic pressure, this position can further compromise respiratory function and is not recommended.
Instructing the client to take slow, deep breaths to prevent further complications is incorrect. The client's condition requires urgent medical intervention, and slow, deep breaths would not address the acute issue of increased intrathoracic pressure and compromised lung function.
Choice A rationale:
Administering diuretics to reduce fluid accumulation is incorrect. Severe dyspnea, absent breath sounds, and jugular venous distension indicate a potential tension pneumothorax or hemothorax, which requires prompt action, and diuretics would not address the underlying issue.
Choice B rationale:
Preparing for needle decompression or chest tube insertion is the appropriate nursing action. The client's symptoms of severe dyspnea, absent breath sounds, jugular venous distension, and increased intrathoracic pressure suggest a possible tension pneumothorax or hemothorax. Immediate decompression with a large-bore needle or insertion of a chest tube is necessary to relieve pressure and restore lung function.
Choice C rationale:
Positioning the client in a Trendelenburg position to facilitate breathing is incorrect. In the case of increased intrathoracic pressure, this position can further compromise respiratory function and is not recommended.
Choice D rationale:
Instructing the client to take slow, deep breaths to prevent further complications is incorrect. The client's condition requires urgent medical intervention, and slow, deep breaths would not address the acute issue of increased intrathoracic pressure and compromised lung function.