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Stripping or milking the chest tube is an outdated practice.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

Explanation

A. Increased anteroposterior diameter of the chest
In emphysema, there is often hyperinflation of the lungs and destruction of the alveolar walls, leading to loss of lung elasticity. This results in increased air trapping and a characteristic "barrel chest" appearance, with an increased anteroposterior diameter.

B. Petechiae on chest:
Petechiae are small, red or purple spots caused by bleeding into the skin. They are not commonly associated with COPD and emphysema.

C. Oxygen saturation level 96%:
Oxygen saturation level of 96% is within the normal range. While oxygen saturation can be affected in COPD, the value provided is not indicative of severe hypoxemia.

D. Respiratory alkalosis:
Respiratory alkalosis is not typically associated with COPD and emphysema. In fact, respiratory acidosis is more commonly seen in these conditions due to impaired gas exchange and retention of carbon dioxide.

A. Place the client in a private room with a special ventilation system. B. Modify the protocol for donning and removing personal protective equipment before entering or leaving the client’s room. C. Have staff and visitors wear gowns, masks, and gloves while in the client’s room. D. Assign the client to a room with other clients who require droplet precautions.

Correct Answer is A

Explanation

A. Place the client in a private room with a special ventilation system.
The primary method to prevent the transmission of tuberculosis is to place the client in a negative pressure room with adequate ventilation. This helps to reduce the risk of airborne transmission of the Mycobacterium tuberculosis bacteria.

B. Modify the protocol for donning and removing personal protective equipment before entering or leaving the client’s room:
Standard precautions should be followed, but the primary emphasis is on airborne precautions due to the potential for airborne transmission of TB. Modifications to donning and removing PPE are not the main focus.

C. Have staff and visitors wear gowns, masks, and gloves while in the client’s room:
Airborne precautions are more specific for suspected active tuberculosis. While gowns, masks, and gloves may be used for other infectious diseases, the key precaution for TB is a private room with negative pressure ventilation.

D. Assign the client to a room with other clients who require droplet precautions:
Tuberculosis is primarily transmitted through airborne particles, not droplets. Placing the client in a room with droplet precautions is not sufficient to prevent the spread of tuberculosis.

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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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