A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?

Loop the tubing of the chest tube on the client’s bed.

Strip the client’s chest tube every 2 hrs.

Place the chest tube drainage system below the level of the client’s heart.

Tape the connections on the client’s chest tube.

Answer and Explanation

The Correct Answer is C

A. Loop the tubing of the chest tube on the client’s bed:
Looping the tubing may create dependent loops that can trap drainage and prevent effective functioning of the chest tube. It can impede the drainage of air or fluid from the pleural space.

B. Strip the client’s chest tube every 2 hrs:
Stripping or milking the chest tube is an outdated practice. It can cause trauma to the tissue surrounding the chest tube and increase the risk of complications, including damage to the lung tissue or tubing.

C. Place the chest tube drainage system below the level of the client’s heart:
This is the correct action. Placing the chest tube drainage system below the level of the client's chest allows gravity to assist with drainage and prevents backflow or accumulation of fluids within the chest tube.

D. Tape the connections on the client’s chest tube:
Taping the connections on the chest tube is not recommended. It is important to keep connections secure, but taping can make it difficult to quickly identify and address any issues with the chest tube system during monitoring and assessment.

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Correct Answer is C

Explanation

A. Discomfort at the puncture site:
Some discomfort at the puncture site is normal after a thoracentesis. It may be managed with pain medication as needed.

B. Serosanguineous drainage from the puncture site:
Serosanguineous drainage (a mix of clear and bloody fluid) is a common and expected finding after a thoracentesis. It is part of the normal post-procedure care.

C. Increased heart rate
Increased heart rate can be indicative of a complication following a thoracentesis, such as a pneumothorax or bleeding. This requires immediate attention, and the healthcare provider should be contacted promptly for further evaluation and intervention.

D. Decreased temperature:
A decreased temperature alone is not typically associated with complications following a thoracentesis. It may be related to other factors, but it is not an immediate concern compared to an increased heart rate.

A. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post meal capillary blood glucose is now 160 mg/dL B. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg C. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6 D. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous

Correct Answer is B

Explanation

A. A client who has a prescription for insulin, and his premeal capillary blood glucose was 110 mg/dL, and his post-meal capillary blood glucose is now 160 mg/dL:
While changes in blood glucose levels are important to monitor, the described change is not as significant as a sudden drop in blood pressure. The blood glucose levels in this scenario are still within a reasonable range.

B. A client whose blood pressure at 0800 was 138/86 mm Hg, and at 1200 is 106/60 mm Hg:
This is the priority client. The significant drop in blood pressure raises concerns about hypovolemia or circulatory issues, which require immediate attention to prevent complications such as inadequate organ perfusion.

C. A client who reports pain as 4 on a scale of 1 to 10 at 0800 and now reports pain as 6:
Pain management is important, but the change in pain intensity from 4 to 6, while indicating an increase, may not be as urgent as addressing a significant drop in blood pressure. Pain assessment and management can be addressed after stabilizing the client with the acute change.

D. A client whose wound drainage at 0800 was sanguineous, and now it is serosanguineous:
Changes in wound drainage color can be important for assessing the healing process, but a shift from sanguineous to serosanguineous is generally within the expected progression of wound healing. It may not require immediate intervention as compared to a significant drop in blood pressure.

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A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?

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