A nurse is caring for a client on the medical-surgical unit.
For each potential nursing action, click to specify if the action is indicated or contraindicated for the client who has a chest tube.
Clamp chest tube when client ambulates.
Report burning pain in chest to provider.
Reinforce dressing around the tube as needed if it loosens.
Maintain water level at 2 cm.
Strip the tubing twice daily to ensure patency
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}
A. Clamping the chest tube during ambulation can lead to increased intrathoracic pressure, which may cause tension pneumothorax or other complications. Chest tubes should remain unclamped to maintain proper drainage. However, it may be done briefly during tube changes or if there is a suspected air leak, always under specific medical orders.
B. Burning pain in the chest could indicate complications such as infection or irritation at the insertion site. Reporting this symptom to the provider allows for timely assessment and intervention.
C. A loose dressing around the chest tube can compromise the integrity of the system, leading to air leaks or contamination. Reinforcing the dressing helps maintain a sterile environment and prevents dislodgement of the tube.
D. Maintaining the appropriate water seal level in the chest drainage system is essential for proper functioning. This prevents air from entering the pleural space while allowing drainage to occur effectively.
E. Stripping or milking the chest tube is no longer a recommended practice as it can cause damage to the tissues and lead to airway obstruction or clot formation. Instead, gentle manipulation or rotation of the tubing may be done if there are signs of occlusion, but routine stripping is not recommended
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Suctioning or any throat examination should be avoided unless absolutely necessary and then only in a controlled environment such as an operating room because it can provoke airway obstruction.
B. While nutrition is important, the priority in acute epiglottitis is maintaining the airway, not dietary content.
C. This intervention is not related to epiglottitis but to conditions affecting pancreatic function.
D. Epiglottitis is a severe, potentially life-threatening infection, and droplet precautions should be initiated to prevent the spread of infection.
Correct Answer is B
Explanation
A: Hypertension is not a typical complication following an amniocentesis; it's more commonly associated with conditions like preeclampsia.
B: Amniocentesis can sometimes trigger premature labor, so monitoring for contractions is essential.
C: Epigastric pain is not a common complication of amniocentesis and may be indicative of other issues such as gastrointestinal problems.
D: Vomiting is not typically associated with amniocentesis, although it can occur due to stress or other factors unrelated to the procedure.
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