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Stripping or milking the chest tube is an outdated practice.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 A
Explanation
A. Cooperating:Cooperating involves working together to find a mutually beneficial solution. In this case, the charge nurse resolves the conflict by allowing both nurses to go to lunch together and taking care of their clients, ensuring that both nurses’ needs are met.
B. Avoiding:Avoiding means ignoring the conflict or withdrawing from the situation. The charge nurse is not ignoring the conflict; rather, they are actively facilitating a resolution by allowing both nurses to take lunch together.
C. Compromising:Compromising involves both parties giving up something to reach a mutually acceptable solution. While the charge nurse is helping to resolve the conflict by allowing the nurses to go to lunch, it does not imply that either nurse has made a concession in their argument, making this option less accurate.
D. Competing:
Competing involves pursuing one's own concerns at the expense of others. It is a win-lose approach to conflict resolution. The charge nurse is not demonstrating a competitive approach in this scenario, as both nurses are accommodated to go to lunch together without one person's needs being prioritized over the other.
Correct Answer is D
Explanation
A. Metabolic alkalosis with full compensation:
This is not the correct interpretation. Metabolic alkalosis is characterized by an elevated pH and elevated bicarbonate (HCO3-) levels. In this case, the pH is low (acidosis), and the bicarbonate level is within the normal range, suggesting a respiratory issue rather than a metabolic one.
B. Respiratory alkalosis with partial compensation:
This is not the correct interpretation. Respiratory alkalosis is characterized by an elevated pH and decreased PaCO2. In this case, the pH is low (acidosis), and the PaCO2 is elevated, indicating respiratory acidosis rather than alkalosis.
C. Metabolic acidosis with partial compensation:
This is not the correct interpretation. Metabolic acidosis is characterized by a low pH and decreased bicarbonate (HCO3-) levels. In this case, the bicarbonate level is within the normal range, and the elevated PaCO2 suggests a respiratory issue, not metabolic acidosis.
D. Respiratory acidosis with no compensation:
This is the correct interpretation. Respiratory acidosis is characterized by a low pH and an elevated PaCO2. The normal bicarbonate level indicates that compensatory mechanisms (such as the kidneys increasing bicarbonate reabsorption) have not fully corrected the pH imbalance, leading to respiratory acidosis with no compensation.
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