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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is an incorrect finding, because ecchymosis of the thigh, or bruising, is not a sign of fat emboli, but a sign of bleeding or hematoma formation due to the fracture or the traction. The nurse should monitor the size and color of the ecchymosis and report any changes to the provider.
Choice B reason: This is an incorrect finding, because serous drainage at the pin site, or clear fluid, is not a sign of fat emboli, but a sign of normal healing or infection. The nurse should assess the amount, color, and odor of the drainage and report any signs of infection, such as purulent drainage, redness, swelling, or pain, to the provider.
Choice C reason: This is the correct finding, because chest petechiae, or small red spots on the chest, are a sign of fat emboli, which are a rare but serious complication of long bone fractures. Fat emboli occur when fat globules from the bone marrow enter the bloodstream and travel to the lungs, causing respiratory distress, hypoxia, and pulmonary edema. The nurse should report any signs of fat emboli, such as chest petechiae, dyspnea, tachypnea, tachycardia, fever, or confusion, to the provider.
Choice D reason: This is an incorrect finding, because muscle spasms in the left leg, or involuntary contractions of the muscles, are not a sign of fat emboli, but a sign of pain, inflammation, or nerve injury due to the fracture or the traction. The nurse should administer analgesics and muscle relaxants as prescribed, and provide comfort measures, such as massage, ice, or elevation, to the client.
Correct Answer is D
Explanation
Choice A reason: This is an important action, but not the first one. The nurse should provide oxygen after lowering the client to the floor and protecting the head, to improve the oxygenation and prevent hypoxia.
Choice B reason: This is an important action, but not the first one. The nurse should turn the client onto his side after lowering the client to the floor and protecting the head, to prevent aspiration and maintain a patent airway.
Choice C reason: This is a helpful action, but not the first one. The nurse should provide privacy after lowering the client to the floor and protecting the head, to respect the client's dignity and reduce the stimulation.
Choice D reason: This is the first action, because lowering the client to the floor and protecting the head can prevent injury and trauma to the client during the seizure. The nurse should use a pillow, blanket, or towel to cushion the head, and move any furniture or objects away from the client.
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