A nurse is assisting with the care of a client who has a newly inserted chest tube. Which of the following actions should the nurse take?
Loop the client's tubes carefully to prevent kinking.
Clamp the tube when the client is ambulating.
Place the client flat to avoid leaks in the tubing.
Keep the collection device below the client's chest level.
The Correct Answer is D
A. Loop the client's tubes carefully to prevent kinking: Tubes should not be unnecessarily looped, as this may cause obstruction or tension.
B. Clamp the tube when the client is ambulating: Clamping increases the risk of tension pneumothorax and should be avoided unless prescribed for specific procedures.
C. Place the client flat to avoid leaks in the tubing: This position may compromise lung expansion; semi-Fowler’s or Fowler’s position is preferred.
D. Keep the collection device below the client’s chest level: This position uses gravity to prevent backflow of fluid or air into the pleural space.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Loop the client's tubes carefully to prevent kinking: Tubes should not be unnecessarily looped, as this may cause obstruction or tension.
B. Clamp the tube when the client is ambulating: Clamping increases the risk of tension pneumothorax and should be avoided unless prescribed for specific procedures.
C. Place the client flat to avoid leaks in the tubing: This position may compromise lung expansion; semi-Fowler’s or Fowler’s position is preferred.
D. Keep the collection device below the client’s chest level: This position uses gravity to prevent backflow of fluid or air into the pleural space.
Correct Answer is B
Explanation
A. More than 250 mL of air moves in and out of the lungs with each breath: This describes tidal volume but does not directly stimulate the cough mechanism.
B. Foreign substances are propelled by the cilia toward the respiratory tract: Irritation by foreign particles stimulates the cough reflex to clear the airways.
C. Dehumidified air enters the upper airway passages: Dry air can cause airway irritation but does not consistently trigger a cough reflex.
D. The blood transports carbon dioxide to the lungs: This describes gas exchange, which does not directly relate to triggering the cough mechanism.
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