A nurse is assisting with the care of a client who has a chest tube in place following a thoracotomy. Which of the following actions should the nurse take?

Empty the drainage container every 4 hr.

Change the client's insertion-site dressing each shift.

Clamp the chest tube when the client is ambulating.

Place the drainage unit below the client's chest level.

Answer and Explanation

The Correct Answer is D

Choice A reason: This is an incorrect action, because emptying the drainage container every 4 hr is not necessary and can interfere with the accurate measurement of the drainage volume. The drainage container should be emptied only when it is full or at the end of the shift.

Choice B reason: This is an incorrect action, because changing the client's insertion-site dressing each shift can increase the risk of infection and dislodgment of the chest tube. The insertion-site dressing should be changed only when it is soiled or loose.

Choice C reason: This is an incorrect action, because clamping the chest tube when the client is ambulating can cause a tension pneumothorax, which is a life-threatening complication of chest tube insertion. The chest tube should be clamped only when ordered by the provider or when changing the drainage system.

Choice D reason: This is the correct action, because placing the drainage unit below the client's chest level can facilitate the drainage of air and fluid from the pleural space by gravity. The drainage unit should be kept below the client's chest level at all times.

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Correct Answer is ["A","B"]

Explanation

Choice A reason: Wearing a gown is a correct action, because it protects the nurse's clothing and skin from exposure to the client's body fluids.

Choice B reason: Wearing gloves is a correct action, because it protects the nurse's hands from contact with the client's body fluids and reduces the risk of transmission of HIV.

Choice C reason: Not needed unless there's risk of respiratory exposure, which is not indicated here. AIDS is not spread via airborne particles.

Choice D reason: Wearing a hair cover is an incorrect action, because it is not necessary for standard precautions or contact precautions, which are the types of isolation required for a client who has AIDS and is incontinent of stool.

Choice E reason: Only needed if splashing of body fluids into the eyes is likely (not typical when simply changing linens).

A. Remain NPO 6 to 8 hr prior to the EEG. B. Take a sedative the night prior to the EEG. C. Thoroughly shampoo hair prior to the EEG. D. Take an additional dose of anticonvulsant medication 30 min prior to the EEG.

Correct Answer is C

Explanation

Choice A reason: This is an incorrect instruction, because the client does not need to remain NPO, or nothing by mouth, before a standard EEG. The client can eat and drink normally, unless the provider instructs otherwise.

Choice B reason: This is an incorrect instruction, because the client should not take a sedative, or any other medication that can affect the brain activity, before a standard EEG. The client should take the usual medications, unless the provider instructs otherwise.

Choice C reason: This is the correct instruction, because the client should thoroughly shampoo hair prior to the EEG. The client should wash the hair with a mild shampoo and rinse well, without using any conditioner, gel, spray, or other hair products. This can help remove any oil, dirt, or residue that can interfere with the placement and function of the electrodes.

Choice D reason: This is an incorrect instruction, because the client should not take an additional dose of anticonvulsant medication before a standard EEG. The client should take the regular dose of anticonvulsant medication, unless the provider instructs otherwise.

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A nurse is assisting with the care of a client who has a chest tube in place following a thoracotomy. Which of the following actions should the nurse take?

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