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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C, weigh the client before and after the treatment. The nurse should weigh the client before and after the treatment to evaluate the effectiveness of the dialysis, and determine whether the appropriate amount of fluid has been removed. Choice A is incorrect because the dialysate should be warmed prior to infusion, not chilled. Choice B is incorrect because sterile gloves, not clean gloves, are required when handling dialysate bags. Choice D is incorrect because diarrhea is not a common complication of peritoneal dialysis.
Choice A: Chilling the dialysate prior to infusion is incorrect because the dialysate should be warmed prior to infusion, not chilled.
Choice B: Using clean gloves when handling dialysate bags is incorrect because sterile gloves, not clean gloves, are required when handling dialysate bags.
Choice D: Monitoring the client for diarrhea is incorrect because diarrhea is not a common complication of peritoneal dialysis.
Correct Answer is D
Explanation
Choice A rationale: Applying an estrogen vaginal cream daily is not a risk factor for osteoporosis. In fact, estrogen can help maintain bone density.
Choice B rationale: Including canned sardines in the diet provides calcium and vitamin D, which are beneficial for bone health.
Choice C rationale: Walking 30 minutes per day is a weight-bearing exercise that helps maintain bone density and is beneficial for preventing osteoporosis.
Choice D rationale: Using a beclomethasone inhaler (a corticosteroid) can be a risk factor for osteoporosis, especially if used long-term, as corticosteroids can lead to bone loss.
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