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 D
Explanation
The correct answer is choice D. Provide regular oral care for the client with a moist swab. When a client with a terminal illness and in the active phase of dying refuses further hydration and nourishment, the nurse should provide comfort measures such as regular oral care to prevent discomfort. The nurse should not force the client to eat or drink or request a prescription for IV fluids. The healthcare surrogate cannot be asked for permission to withhold nourishment as the client has the right to refuse nourishment.
Option A - The client has the right to refuse nourishment, and healthcare surrogate permission is not required.
Option B - Requesting a prescription for IV fluids is not an appropriate intervention as the client has the right to refuse nourishment.
Option C - Explaining the importance of oral hydration to the client is not an appropriate intervention as the client has the right to refuse nourishment.
Correct Answer is D
Explanation
The correct answer is choice D. Requires nasogastric suction.
Nasogastric suction removes gastric secretions that contain potassium, leading to a loss of potassium from the body.
This can cause hypokalemia, which is a low level of potassium in the blood.
Choice A is wrong because Addison’s disease causes hyperkalemia, which is a high level of potassium in the blood.
Choice B is wrong because tissue damage can release potassium from the cells into the blood, causing hyperkalemia.
Choice C is wrong because uric acid level is not related to potassium level.
Uric acid is a waste product of purine metabolism that can cause gout or kidney stones if elevated.
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