Clinical Nurse Leader Practice Exam

What is a priority action for the CNL when performing rounds with a physician on a patient with a chest tube?

1. The patient has continued pain where the chest tube was placed

2. There is no diet ordered for this patient

3. The patient's incentive spirometer results decreased from 1500 to 750

4. The patient complains of a sore throat

The correct answer is: The patient's incentive spirometer results decreased from 1500 to 750

In the context of a patient with a chest tube, monitoring the effectiveness of respiratory function is critical. The patient's decreasing incentive spirometer results from 1500 to 750 indicate a significant reduction in their lung capacity or effort. This change is concerning because it may suggest a potential complication, such as atelectasis or fluid accumulation in the pleural space, that could severely affect the patient's respiratory status. In the role of a Clinical Nurse Leader, prioritizing respiratory function is crucial, especially when a patient has a chest tube, as the device is often used to facilitate lung re-expansion and alleviate respiratory distress. The responsibility includes ensuring that interventions are in place to optimize lung function and manage any associated symptoms effectively. While the other options present valid concerns for patient care, none carry the same level of immediate urgency. The pain at the chest tube site may be managed with adequate pain control but does not directly indicate a critical change in respiratory function. The lack of a diet order and the complaint of a sore throat are important to address but are not as immediately pressing as the decline in the patient's incentive spirometer readings, which can have an immediate impact on their overall stability. Thus, recognizing the significance of the patient’s respiratory status is paramount.