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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: An open fracture, while needing medical attention, is not immediately life-threatening. The client's condition is stable enough to wait while more critical cases are attended to.

Choice B reason: A penetrating head injury with seizures is a critical condition. However, ensuring a patent airway takes precedence in emergency situations. This client's seizures indicate serious brain injury, but the immediate threat to life, such as airway obstruction, must be prioritized.

Choice C reason: Severe respiratory stridor and a deviated trachea indicate a life-threatening airway obstruction. This client needs immediate attention to secure the airway and prevent respiratory failure. This is the highest priority because without a clear airway, the client will not survive long enough to benefit from other interventions.

Choice D reason: A partial-thickness burn, although painful and requiring treatment, is not immediately life-threatening. This client can safely wait while those with more critical needs are attended to.

A. "I took a laxative yesterday." B. "I took my metformin before breakfast." C. "I haven't had anything to eat or drink since last night." D. "The last time I voided it was painful."

Correct Answer is B

Explanation

Choice A reason: Taking a laxative the day before an IVP is a common preparation to clear the intestines for better imaging. This statement does not require additional data collection.

Choice B reason: The correct answer is b because taking metformin before an IVP can increase the risk of lactic acidosis, a serious complication. Metformin should be temporarily discontinued before and after the procedure, and the nurse should gather more information to manage the client’s diabetes safely.

Choice C reason: Fasting before an IVP is standard procedure to ensure clear imaging. This statement does not require additional data collection.

Choice D reason: Painful voiding may be related to kidney stones but is not a contraindication for an IVP. This statement does not require additional data collection.

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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?

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