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 B

Explanation

BUN 40 mg/dL. Elevated BUN levels can indicate impaired kidney function, which can be a potential adverse effect of long-term NSAID therapy.

Reasons why the other options are not answers:

Option A: Total bilirubin 0.8 mg/dL is a normal value and does not require reporting to the provider.

Option C: PaO2 90 mm Hg is within the normal range and does not require reporting to the provider.

Option D: Hematocrit 45% is within the normal range and does not require reporting to the provider.

A. "I will perform breast exams every other month." B. "It is common for the skin on my breasts to dimple." C. "It is common for one breast to be larger than the other." D. "I will perform breast exams the day my period begins."

Correct Answer is C

Explanation

Choice A rationale: Breast self-examinations should be performed monthly, not every other month. This regularity helps with early detection of any changes.

Choice B rationale: Dimpling of the skin on the breasts is not common and can be a sign of breast cancer or other conditions. This statement indicates a misunderstanding.

Choice C rationale: It is indeed common for one breast to be slightly larger than the other. This is a normal variation and not usually a cause for concern.

Choice D rationale: Breast self-examinations should be performed several days after the menstrual period ends, not the day the period begins. This timing helps to reduce the likelihood of hormonal changes affecting breast tissue.

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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?

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