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

Empty the drainage collection chamber when full.

Ensure bubbling is present in the water-seal chamber.

Milk the chest tube at least three times per day.

Clamp the chest tube when transferring the client from bed to chair.

Answer and Explanation

The Correct Answer is A

Rationale

A. Empty the drainage collection chamber when full: Maintaining an appropriate level of drainage ensures the system functions effectively and reduces the risk of infection or complications. The collection chamber must be replaced when the drainage volume reaches the maximum limit or when specified by policy, ensuring the system remains closed.

B. Ensure bubbling is present in the water-seal chamber: Continuous bubbling in the water-seal chamber is abnormal and may indicate an air leak. Intermittent bubbling with respirations is expected, but constant bubbling requires assessment and correction rather than being a desired finding.

C. Milk the chest tube at least three times per day: Milking or stripping the chest tube is generally discouraged because it can create high negative pressures, potentially injuring lung tissue. Modern recommendations advise gentle manipulation only if necessary and as per provider guidance.

D. Clamp the chest tube when transferring the client from bed to chair: Clamping the chest tube can cause a tension pneumothorax and is unsafe unless specifically ordered for a diagnostic procedure. The tube should remain patent during movement to allow continued drainage and prevent complications.

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Correct Answer is D

Explanation

Rationale

A. Oral temperature 37.4° C (99.3° F): This temperature is within normal limits and does not indicate a concerning postoperative complication. Mild elevations can occur due to surgery or mild inflammatory responses, but this finding alone does not require provider notification.

B. BP 130/84 mm Hg: This blood pressure reading is slightly elevated but generally within acceptable postoperative limits. It does not indicate immediate risk from opioid therapy and does not necessitate urgent reporting.

C. Heart rate 88/min: A heart rate in the high-normal range is not unusual postoperatively and is not concerning in the context of opioid administration. Monitoring should continue, but this finding does not require immediate provider notification.

D. Respiratory rate 10/min: A respiratory rate below 12 breaths per minute is considered bradypnea and may indicate opioid-induced respiratory depression. This is a potentially life-threatening complication that requires immediate notification of the provider and prompt intervention to ensure adequate ventilation and oxygenation.

A. Contact B. Airborne C. Protective D. Droplet

Correct Answer is B

Explanation

Rationale

A. Contact: Contact precautions are used for infections spread by direct or indirect contact, such as C. difficile or MRSA. Measles is not primarily transmitted via contact, so contact precautions alone are insufficient.

B. Airborne: Measles is highly contagious and transmitted via airborne respiratory droplets that can remain suspended in the air. Airborne precautions, including placing the client in a negative-pressure room and requiring staff to wear N95 respirators, are necessary to prevent transmission.

C. Protective: Protective (or neutropenic) precautions are designed to protect immunocompromised clients from infection. They are not appropriate for preventing the spread of measles from an infected client.

D. Droplet: Droplet precautions are used for infections spread by larger respiratory droplets, such as influenza or pertussis. Measles requires airborne precautions because the virus can travel on smaller particles and remain suspended in the air for extended periods.

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

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