A nurse is caring for a client who has a chest tube inserted for a pneumothorax. Which of the following actions should the nurse take?
Empty the collection chamber on the client’s chest tube every 4 hr.
Strip the client’s chest tube every 2 hr.
Pin the chest tube to the client’s gown.
Tape the connections on the client’s chest tube.
The Correct Answer is D
Choice A reason: Emptying the collection chamber every 4 hours is unnecessary and can increase the risk of introducing infection. The chamber should be emptied as needed based on the volume of drainage.
Choice B reason: Stripping the chest tube, which involves squeezing and releasing sections of the tube to move clots, is not recommended as it can create high negative pressure and cause damage to the lung tissue.
Choice C reason: Pinning the chest tube to the client’s gown can lead to accidental dislodgement. The chest tube should be secured appropriately without tension.
Choice D reason: The correct answer is d because taping the connections on the client’s chest tube ensures that the system remains airtight and prevents air leaks, which is essential for effective functioning of the chest tube and prevention of pneumothorax recurrence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Keeping the television on at all times can contribute to overstimulation and confusion for clients with Alzheimer's disease. It is better to have the television on at specific times and choose calming, familiar programs.
Choice B reason: Hanging abstract pictures on the walls can be confusing and disorienting for clients with Alzheimer's disease. Simple, familiar images or family photographs are more helpful in creating a comforting environment.
Choice C reason: The correct answer is c because keeping familiar personal items in the client's room can provide a sense of security and comfort. Familiar objects can help reduce confusion and anxiety in clients with Alzheimer's disease.
Choice D reason: While adequate lighting is important, bright lighting can sometimes cause discomfort or glare. It is better to have soft, consistent lighting that helps the client feel safe and oriented without causing overstimulation.
Correct Answer is B
Explanation
Choice A reason: Fresh fruits and vegetables can harbor bacteria and other pathogens that pose a significant infection risk to neutropenic clients. It's advisable to avoid these foods unless they are cooked or properly washed and peeled.
Choice B reason: Avoiding crowded places is essential for neutropenic clients because their immune system is weakened, making them more susceptible to infections. Crowded places increase the risk of exposure to infectious agents.
Choice C reason: Participating in gardening is not recommended as it exposes neutropenic clients to soil bacteria and fungi, which can cause infections. Activities should be chosen carefully to minimize infection risk.
Choice D reason: Taking temperature weekly is not adequate for neutropenic clients. Daily temperature monitoring is important for early detection of infections, which can progress rapidly in immunocompromised individuals.
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