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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A, participate in reminiscence therapy with the client. This is an effective intervention for individuals with Alzheimer's disease. It involves encouraging the client to discuss past experiences and events. It has been shown to improve mood, decrease agitation, and increase communication skills. The reminiscence therapy should be individualized and tailored to the client's interests and abilities.
- Raising the four side rails on the client's bed is not the correct answer because this could cause harm to the client by restricting their mobility and independence.
- Alternating the client's daily routine is not the correct answer because individuals with Alzheimer's disease benefit from a consistent routine, which helps them to feel more secure and less anxious.
- Keeping the lights dimmed is not the correct answer because it can be disorienting and confusing for clients with Alzheimer's disease, who need adequate lighting to distinguish their surroundings.
Correct Answer is A
Explanation
The correct answer is choice a. Limit fluid intake during meals.
Choice A rationale:
Limiting fluid intake during meals can help prevent the stomach from becoming too full, which can make breathing more difficult for someone with COPD.
Choice B rationale:
Eliminating dairy products is not typically recommended for COPD patients unless they have a specific intolerance or allergy. Dairy does not generally affect COPD symptoms.
Choice C rationale:
Consuming three regular meals daily might be challenging for COPD patients who often have reduced appetite and may benefit more from smaller, frequent meals.
Choice D rationale:
Eating lighter, low-calorie foods first is not advisable for COPD patients who need nutrient-dense foods to maintain their energy levels and overall health.
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