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 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Bacteria are not detected by the stool guaiac test. The stool guaiac test is a chemical test that reacts with hemoglobin, a protein found in red blood cells. Bacteria are microorganisms that do not contain hemoglobin.
Choice B reason: Fat is not detected by the stool guaiac test. The stool guaiac test is a chemical test that reacts with hemoglobin, a protein found in red blood cells. Fat is a lipid that does not contain hemoglobin.
Choice C reason: Parasites are not detected by the stool guaiac test. The stool guaiac test is a chemical test that reacts with hemoglobin, a protein found in red blood cells. Parasites are organisms that live in or on another host and do not contain hemoglobin.
Choice D reason: Blood is detected by the stool guaiac test. The stool guaiac test is a chemical test that reacts with hemoglobin, a protein found in red blood cells. Blood can indicate bleeding in the gastrointestinal tract, which can be caused by various conditions such as ulcers, polyps, or cancer.
Correct Answer is A
Explanation
Choice A reason: Metabolic alkalosis is a condition in which the blood pH is elevated due to an excess of bicarbonate or a loss of acid. It can be caused by nausea and vomiting, as they result in the loss of gastric acid and the retention of bicarbonate.
Choice B reason: Respiratory acidosis is a condition in which the blood pH is lowered due to an accumulation of carbon dioxide. It can be caused by hypoventilation, airway obstruction, or lung diseases. It is not related to nausea and vomiting.
Choice C reason: Metabolic acidosis is a condition in which the blood pH is lowered due to an excess of acid or a loss of bicarbonate. It can be caused by diabetic ketoacidosis, renal failure, or lactic acidosis. It is not caused by nausea and vomiting.
Choice D reason: Respiratory alkalosis is a condition in which the blood pH is elevated due to a loss
carbon dioxide. It can be caused by hyperventilation, anxiety, fever, or aspirin overdose. It is not common in clients who have nausea and vomiting.
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