A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?

Disconnect the chest tube from the drainage system during transport.

Empty the collection chamber prior to transport.

Clamp the chest tube prior to transferring the client to a wheelchair.

Keep the drainage system below the level of the client's chest at all times.

Answer and Explanation

The Correct Answer is D

Keeping the drainage system below the level of the client's chest prevents backﬂow of ﬂuid or air into the
pleural space and maintains negative pressure in the system.

a)   Disconnecting the chest tube from the drainage system during transport is dangerous and can cause pneumothorax, infection, or bleeding. The chest tube should remain connected to the drainage system at all times unless ordered by the provider.
b)   Emptying the collection chamber prior to transport is unnecessary and can interfere with accurate measurement of drainage. The collection chamber should be emptied only when it is full or at the end of each shift.
c)   Clamping the chest tube prior to transferring the client to a wheelchair is contraindicated and can cause tension pneumothorax, as it prevents air from escaping the pleural space. The chest tube should only be clamped for a brief period when changing the drainage system or checking for air leaks, and only with a provider's order.

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Correct Answer is ["A","B","D"]

Explanation

A. Dyspnea:
Dyspnea (shortness of breath) is a common symptom in emphysema due to the destruction of alveolar walls and the resulting reduction in surface area for gas exchange. As the disease progresses, the patient experiences increasing difficulty in breathing, especially during exertion or when the disease becomes more severe.

B. Barrel chest:
A barrel chest is often seen in emphysema, as it results from hyperinflation of the lungs. The increased air trapping due to damaged alveoli causes the chest to expand and become rounded, leading to the characteristic "barrel chest" appearance. This happens because the lungs are constantly overinflated, and the chest wall becomes rigid and rounded as a result.

D. Clubbing of the fingers:
Clubbing of the fingers can occur in chronic respiratory conditions like emphysema due to prolonged hypoxia (low oxygen levels in the blood). This is a compensatory mechanism that involves changes in the nails and fingers. The tips of the fingers become rounded and bulbous over time, and this is commonly associated with long-standing pulmonary diseases.

A. "We'll continue to encourage him to drink lots of ﬂuids." B. "We'll take his temperature every 4 hours." C. "We'll discard his toothbrush and buy another." D. "We'll give him Tylenol for the pain."

Correct Answer is C

Explanation

Discarding the toothbrush and buying another is a way to prevent disease transmission, as the toothbrush can harbor bacteria and reinfect the child or spread the infection to others. The toothbrush should be discarded after 24 hours of antibiotic therapy.

a) Encouraging the child to drink lots of ﬂuids is a way to promote hydration and soothe the throat, but it does not prevent disease transmission. The child should avoid sharing cups or utensils with others and use disposable tissues or paper towels.
b) Taking the child's temperature every 4 hours is a way to monitor fever, but it does not prevent disease transmission. The thermometer should be cleaned and disinfected after each use and not shared with others.
d) Giving the child Tylenol for the pain is a way to relieve discomfort, but it does not prevent disease transmission. The medication should be administered according to the label instructions and not shared with others.

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A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply)

Correct Answer is ["A","B","D"]

Explanation

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Correct Answer is C

Explanation

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