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

Monitor for at least 150 mL of drainage every hour.

Clamp the tube for 30 min every 8 hr.

Pin the tubing to the client's bed sheets.

Replace the unit when the drainage chamber is full.

Answer and Explanation

The Correct Answer is A

Monitor for at least 150 mL of drainage every hour. The nurse should monitor the chest tube drainage for excessive or sudden increases in order to detect any complications, such as pneumothorax. Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications. Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided. The chest tube unit should only be replaced when there is a problem with the unit or the seals.

Choice B: Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications.

Choice C: Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided.

Choice D: The chest tube unit should only be replaced when there is a problem with the unit or the seals.

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Correct Answer is A

Explanation

The correct answer is choice A. Weight-bearing exercise is an important way to decrease the risk of osteoporosis in a postmenopausal client. Choice B is incorrect because calcium carbonate supplements should be taken multiple times throughout the day for better absorption. Choice C is incorrect because vitamin D intake should be increased. Choice D is incorrect because there is no evidence that vitamin E intake decreases the risk of osteoporosis. Choice B is not correct because calcium carbonate supplements should be taken multiple times throughout the day for better absorption. Choice C is not correct because vitamin D intake should be increased.

A. Place the client in high-Fowler's position. B. Obtain the client's vital signs. C. Administer heparin to the client. D. Encourage the client to cough and deep breathe.

Correct Answer is A

No explanation

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

Nursing Test Bank

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