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.

Answer and Explanation

The Correct Answer is D

Choice A reason: Stripping the client's chest tube every 2 hours is not a recommended action, as it can cause excessive negative pressure, tissue trauma, and pain. The nurse should only strip the chest tube if there is a clot or obstruction in the tubing, and only with the provider's order.

Choice B reason: Looping the tubing of the chest tube on the client's bed is a correct action, as it prevents kinking, tension, or pulling on the chest tube. The nurse should also secure the tubing to the bed sheet with a safety pin.

Choice C reason: Placing the chest tube drainage system above the level of the client's heart is not a correct action, as it can cause the fluid to flow back into the chest cavity and impair lung expansion. The nurse should place the chest tube drainage system below the level of the client's chest.

Choice D reason: Taping the connections on the client's chest tube is a correct action, as it prevents air leaks, disconnections, or accidental removal of the chest tube. The nurse should also check the connections regularly for tightness and patency.

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Correct Answer is D

Explanation

Choice A reason: Prone is not the best position to allow maximal lung expansion. Prone is a position where the client lies on their stomach, with their head turned to one side. Prone can help to improve oxygenation in some cases of acute respiratory distress syndrome (ARDS), but it can also increase the risk of pressure ulcers, facial edema, and airway obstruction.

Choice B reason: Side-lying is not the best position to allow maximal lung expansion. Side-lying is a position where the client lies on their side, with their head supported by a pillow. Side-lying can help to prevent aspiration and reduce the work of breathing in some clients, but it can also compromise the ventilation of the dependent lung.

Choice C reason: Supine is not the best position to allow maximal lung expansion. Supine is a position where the client lies on their back, with their head and shoulders slightly elevated. Supine can help to maintain a patent airway and facilitate suctioning in some clients, but it can also increase the risk of atelectasis, pneumonia, and hypoxemia.

Choice D reason: Upright is the best position to allow maximal lung expansion. Upright is a position where the client sits or stands with their back straight and their chest expanded. Upright can help to improve lung compliance, reduce airway resistance, and enhance gas exchange in clients with respiratory failure. Upright can also reduce the pressure on the diaphragm and abdominal organs, and promote the drainage of secretions.

A. Respiratory rate 28/min B. Pink mucous membranes C. Heart rate 110/min D. Restlessness

Correct Answer is B

Explanation

Choice A reason: Respiratory rate 28/min is not a sign of effective oxygen therapy, as it indicates tachypnea, which is a rapid breathing rate. Tachypnea can be caused by hypoxia, anxiety, fever, or pain.

Choice B reason: Pink mucous membranes are a sign of effective oxygen therapy, as they indicate adequate oxygenation of the tissues. Pink mucous membranes are a normal finding, while pale, cyanotic, or jaundiced mucous membranes can indicate hypoxia or other problems.

Choice C reason: Heart rate 110/min is not a sign of effective oxygen therapy, as it indicates tachycardia, which is a rapid heart rate. Tachycardia can be caused by hypoxia, stress, dehydration, or infection.

Choice D reason: Restlessness is not a sign of effective oxygen therapy, as it indicates agitation, anxiety, or discomfort. Restlessness can be caused by hypoxia, pain, or medication side effects.

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

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