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Stripping or milking the chest tube is an outdated practice.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 D

Explanation

A. Encourage oral intake of at least 3,000 mL of fluids per day:
This is not a priority intervention for ARDS. While maintaining adequate hydration is important, the primary focus in ARDS is on respiratory support and oxygenation. Excessive fluid intake may exacerbate pulmonary edema in these patients.

B. Offer high-protein and high-carbohydrate foods frequently:
Nutritional support is important in ARDS, but the primary concern is oxygenation and respiratory function. Offering high-protein and high-carbohydrate foods can support the client's overall nutritional needs, but it may not directly address the respiratory distress.

C. Administer low-flow oxygen continuously via nasal cannula:
This is not typically sufficient for ARDS. ARDS often requires higher levels of oxygen support, and low-flow oxygen may not meet the increased oxygen demand. More aggressive oxygenation strategies, such as non-invasive positive pressure ventilation (NIPPV) or mechanical ventilation, may be necessary.

D. Place in a prone position:
Placing the patient in a prone position is a recommended intervention for ARDS. Prone positioning can improve oxygenation by optimizing ventilation-perfusion matching and reducing pressure on the lungs. This intervention is aimed at improving respiratory function in ARDS patients.

A. “I have not received any of my medications today.” B. “Do you know when I will be going home?” C. “I do not know how to make the remote control work.” D. “My dressing was changed earlier this morning.”

Correct Answer is A

Explanation

A. “I have not received any of my medications today.”
The statement "I have not received any of my medications today" requires follow-up from the nurse because it indicates a potential issue with the client's medication administration. It's important to ensure that the client receives the prescribed medications in a timely manner.

B. “Do you know when I will be going home?”
This is a question about the discharge plan and does not indicate an immediate issue that requires follow-up.

C. “I do not know how to make the remote control work.”
While it's a statement about the client's understanding of the remote control, it is not an urgent matter that requires immediate attention.

D. “My dressing was changed earlier this morning.”
This statement indicates that a care task (dressing change) has been completed and does not suggest a problem that requires urgent follow-up.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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