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 B
Explanation
A. Epoetin alfa does not directly affect platelet count.
B. Epoetin alfa is a medication used to stimulate red blood cell production in patients with anemia. A therapeutic response to epoetin alfa would include an increase in hemoglobin level, indicating improved oxygen-carrying capacity of the blood.
C. Epoetin alfa does not directly affect neutrophil count.
D. Erythrocyte sedimentation rate is a nonspecific marker of inflammation and is not directly affected by epoetin alfa.
Correct Answer is C
Explanation
A. Petroleum jelly is a petroleum-based product and can be a fire hazard when used with oxygen therapy. Water-based lubricants are recommended instead.
B. Alcohol is flammable, so it's better to avoid alcohol-based cleaners near oxygen therapy equipment.
C. Nail polish remover typically contains acetone, which is highly flammable. Since oxygen therapy increases the risk of fires, it is essential to avoid flammable substances around the client.
D. Synthetic fabrics can generate static electricity and should be avoided around oxygen. Cotton is preferable because it is less likely to produce static.
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