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.
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Stripping or milking the chest tube is an outdated practice.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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. An increase in the CMV rate:
Increasing the continuous mandatory volume (CMV) rate would provide more mandatory breaths, which may not address the patient's respiratory acidosis. It could potentially worsen the situation by causing respiratory alkalosis.
B. Change to SIMV (Synchronized Intermittent Mandatory Ventilation) MODE
The patient's arterial blood gas results indicate respiratory acidosis with an elevated PaCO2 (50 mmHg) and a low pH (7.30). The nurse would recommend changing to SIMV mode to allow for spontaneous breaths in addition to the set mandatory breaths. This change helps the patient to have more control over their respiratory efforts and may assist in lowering the PaCO2.
C. A decrease in the PaO2:
Decreasing the partial pressure of oxygen (PaO2) is not an appropriate response, especially when the patient is already on mechanical ventilation and has a moderate PaO2 level. The primary concern is the elevated PaCO2 and respiratory acidosis.
D. A decrease in the CMV rate:
Decreasing the CMV rate would reduce the number of mandatory breaths, potentially allowing the patient to hypoventilate further and retain more carbon dioxide. This is not the appropriate intervention for a patient with respiratory acidosis.
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.
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