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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Related Questions
Correct Answer is C
Explanation
The client should wear a mask during transport to prevent the spread of infectious droplets. The nurse should wear appropriate personal protective equipment (PPE) based on the precautions required for the specific client, which in this case would be a mask. The nurse does not need to wear a gown as droplet precautions do not require the use of a gown during transport.
The correct answer is choice C, the client should wear a mask during transport.
Choice A rationale:
The client wearing a gown during transport is not typically necessary for droplet precautions unless there is a risk of the gown becoming contaminated with infectious material. Gowns are primarily used to protect the healthcare worker or other patients if there is direct contact with the patient.
Choice B rationale:
While the nurse should wear a mask if they will be within close proximity to the client, the primary concern in droplet precautions is to prevent the spread of infection from the client, who is the source of the droplets.
Choice C rationale:
The client should wear a mask during transport to contain respiratory secretions and minimize the risk of droplet spread, as droplets can be disseminated by coughing, sneezing, or talking. This is a key component of source control in droplet precautions.
Choice D rationale:
Similar to choice A, the nurse wearing a gown during transport is not a standard requirement for droplet precautions unless there is anticipated contact with the patient or their environment that might result in contamination.
In summary, the primary goal of droplet precautions is to prevent the spread of infections through large respiratory droplets that are expelled by the client. Therefore, having the client wear a mask is the most effective measure among the options provided to reduce the risk of transmission during transport.
Correct Answer is D
Explanation
The correct answer is choice D, "I should adjust the TENS unit until I feel a tingling sensation." This is an appropriate statement that indicates the client understands how to use the TENS unit. The TENS unit works by sending electrical impulses to the nerves to block pain signals. The client should adjust the unit until they feel a tingling sensation, which is the desired effect.
"The TENS unit administers a continuous dose of pain medication" is not the correct answer because the TENS unit does not administer medication.
"I will need to charge the TENS unit for 2 hours each day" is not the correct answer because the TENS unit is battery operated and does not need to be charged.
"The TENS unit should be applied at least 6 inches from the actual site of my pain" is not the correct answer because the electrodes should be placed directly on the site of the pain.
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