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: Elevated toilet seats are often recommended following hip surgery to reduce strain, not increase the risk of injury.
B: No stairs in the home is generally a positive feature for a client following hip surgery, reducing fall risk.
C: A reclining chair with a straight back may provide comfortable seating without increasing the risk of injury.
D: A large soaking tub without a shower head can increase the risk of falls and injury due to difficulty getting in and out of the tub, especially for a client recovering from hip surgery.
Correct Answer is B
Explanation
A. Provide 60 mL (2 oz) of fluid intake every 5 min. Immediately post-surgery, fluid intake is usually more restricted and administered in smaller, more controlled quantities to prevent strain on the surgical site.
B. After gastric bypass surgery, monitoring for signs of complications such as leaks, obstructions, or internal bleeding is crucial. Measuring abdominal girth daily is not typically necessary unless specific complications are suspected.
C. Introducing a soft diet immediately post-surgery is typically delayed to allow healing; patients usually start with clear liquids.
D. Early ambulation is generally encouraged postoperatively to prevent complications like deep vein thrombosis and to promote gastrointestinal function, often starting as soon as the first postoperative day.
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