A nurse is assisting with the care of a client who has a chest tube.
Which of the following actions should the nurse take?
Strip the client’s chest tube every 2 hours.
Loop the tubing of the chest tube on the client’s bed.
Place the chest tube drainage system above the level of the client’s heart.
Tape the connections on the client’s chest tube.
The Correct Answer is D
Choice A rationale:
Stripping the client’s chest tube every 2 hours is not recommended. Stripping can create high negative pressures in the tube that can cause damage to the lung tissue. It can also lead to increased pain for the patient and is generally not a standard practice in chest tube management.
Choice B rationale:
Looping the tubing of the chest tube on the client’s bed is not a recommended practice. The chest tube should be free of loops or kinks to allow for proper drainage of air and fluid from the pleural space. Any loops or kinks in the tube can lead to accumulation of fluid or air, which can cause complications such as tension pneumothorax.
The chest tube drainage system should not be placed above the level of the client’s heart. This can lead to the backflow of blood or fluid into the pleural space, which can cause complications such as hemothorax or pleural effusion. The drainage system should always be kept below the level of the client’s chest to allow for gravity-assisted drainage.
Choice D rationale:
Taping the connections on the client’s chest tube is a recommended practice. This is done to secure the connections and prevent accidental disconnection or dislodgement of the tube. An accidental disconnection or dislodgement can lead to complications such as pneumothorax or hemothorax. Therefore, all connections should be securely taped to prevent any accidental disconnections.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A rationale:
Crackles are a common symptom of pleural effusion. They are abnormal lung sounds that are heard when a patient with pleural effusion breathes in. The sound is caused by the opening of small airways and alveoli collapsed by fluid, exudate, or lack of aeration during expiration.
Choice B rationale:
Crepitus is not typically associated with pleural effusion. Crepitus is a crackling or grating sound or feeling produced by air in subcutaneous tissue or by the rubbing together of fragments of broken bone. In the context of respiratory health, crepitus might be felt if there is subcutaneous emphysema, where air gets into tissues under the skin covering the chest wall or neck.
Choice C rationale:
Substernal retractions are not a typical symptom of pleural effusion. Retractions are a sign of respiratory distress, but they are more commonly associated with conditions that cause upper airway obstruction or severe lung disease, such as asthma or pneumonia. Choice D rationale:
Dullness upon percussion is a classic sign of pleural effusion. When there is fluid in the pleural space, it prevents the normal resonant sound produced by the air-filled lungs from being heard. Instead, a dull sound is heard when the chest is percussed.
Correct Answer is D
Explanation
Choice A rationale:
Prone The prone position, in which a patient lies facedown, is beneficial for patients with pneumonia as it helps shift the fluid away from the back of the lungs, allowing more air to enter. It also improves ventilation in the lungs and reduces the risk of lung collapse. However, this position is not the most effective for maximum lung expansion in pneumonia patients.
Choice B rationale:
Side-lying Lateral positioning, in which the patient lies on one side, is recommended for patients suffering from pneumonia in just one lung. In this position, the pneumatic lung is exposed to a higher blood flow, resulting in greater oxygenation levels and improved lung expansion. This position can also help prevent lung injury by helping regulate pressure and improve aeration.
But again, this is not the most effective position for maximum lung expansion in pneumonia patients.
Choice C rationale:
Supine The supine position, where the patient lies flat on their back, is not the best position for a pneumonia patient. This position can cause the secretions to pool in the lungs, making it harder for the patient to breathe and potentially worsening their condition. Choice D rationale:
Upright Elevating the head of the bed is an effective way to improve lung expansion and oxygenation levels in pneumonia patients. This position also helps eliminate airway obstruction, reduces pressure on the lungs, and promotes drainage of fluids from the lungs. Therefore, the upright position is the most recommended for maximum lung expansion in pneumonia patients.
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