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?

Milk the chest tube at least three times a day

Empty the drainage collection chamber when full

Ensure intermittent bubbling is present in the water seal chamber

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

Answer and Explanation

The Correct Answer is C

A. Milk the chest tube at least three times a day: Milking is generally not recommended as it can increase intrathoracic pressure and damage lung tissue. It should only be done with a provider’s order and specific indication.

B. Empty the drainage collection chamber when full: The collection chamber is a closed system and should not be emptied. When full, the entire drainage unit should be replaced to maintain sterility.

C. Ensure intermittent bubbling is present in the water seal chamber: Intermittent bubbling in the water seal chamber is expected during expiration or coughing, indicating air leaving the pleural space. However, continuous bubbling may suggest an air leak and requires evaluation.

D. Clamp the chest tube when transferring the client from bed to the chair: Clamping the tube is contraindicated during transport, as it can cause tension pneumothorax. The system should remain unclamped and below chest level.

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Correct Answer is D

Explanation

A. Depression: Depression typically involves feelings of sadness, despair, and withdrawal. The client's statement about wanting comfort, rather than prolonged sadness, reflects acceptance, not depression.

B. Bargaining: Bargaining is when individuals try to make deals to reverse their situation, often asking for more time. The client’s statement reflects a decision to stop treatment, not bargaining for more time.

C. Denial: Denial involves refusing to acknowledge the reality of the situation. The client’s statement shows recognition of their condition and prioritizing comfort, which shows acceptance rather than denial.

D. Acceptance: In the acceptance stage, individuals come to terms with their diagnosis and focus on achieving peace. The client’s request for comfort care is consistent with acceptance, where they focus on making the most of their time.

A. Warm skin B. Restlessness C. Bounding pulses D. Brisk capillary refill

Correct Answer is B

Explanation

A. Warm skin: Warm skin typically indicates good circulation and is not a specific sign of active bleeding. Active bleeding is more likely to cause signs like cool or pale skin due to decreased perfusion.

B. Restlessness: Restlessness is a common sign of hypovolemia or decreased oxygen perfusion, both of which can be caused by active bleeding. It may indicate that the client is experiencing discomfort, anxiety, or shock due to blood loss.

C. Bounding pulses: Bounding pulses are typically associated with conditions like fever or increased blood volume, not bleeding. Active bleeding usually results in weak, thready pulses due to decreased blood volume.

D. Brisk capillary refill: A brisk capillary refill time (less than 2 seconds) is generally a sign of adequate circulation, not bleeding. In the case of active bleeding, capillary refill may be delayed due to reduced blood flow.

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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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