A nurse is caring for a client who has a three-chamber chest tube system. Which of the following actions should the nurse take?
Ensure 2 cm (0.8 in) of water is in the water seal chamber.
Check the patency of the tubing every 2 hr.
Keep the drainage system above the level of the client's chest.
Empty the collection chamber every 8 hr.
The Correct Answer is A
A. Ensure 2 cm (0.8 in) of water is in the water seal chamber. This is correct because maintaining the correct water level in the water seal chamber is essential for proper functioning of the chest tube system, as it prevents air from entering the pleural space.
B. Check the patency of the tubing every 2 hr. This is incorrect because continuous monitoring is required, and patency should be ensured at all times, not just at set intervals. However, frequent assessments are important.
C. Keep the drainage system above the level of the client's chest. This is incorrect because the drainage system should be kept below chest level to allow gravity drainage and prevent backflow into the pleural space.
D. Empty the collection chamber every 8 hr. This is incorrect because the collection chamber should only be emptied when full, following facility protocol, to maintain an accurate record of drainage output.
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Related Questions
Correct Answer is C
Explanation
A. Reinserting the protruding intestinal tissue is inappropriate and can cause further injury or infection. The nurse should keep the tissue moist and protected until surgical intervention.
B. Placing the client in Trendelenburg position is incorrect because it does not reduce tension on the wound. Instead, the client should be placed in a low Fowler's position with knees slightly flexed to reduce strain.
C. Covering the wound with a sterile saline-soaked dressing is the priority action to keep the tissue moist and prevent further contamination or damage until the provider can intervene.
D. Monitoring vital signs every 30 minutes is important but not the priority action. The nurse should immediately cover the wound first, then monitor for signs of shock or infection.
Correct Answer is C
Explanation
A. Rotavirus vaccine is for infants, not older adults. It is given to prevent severe diarrhea caused by rotavirus.
B. Human papillomavirus (HPV) vaccine is recommended for adolescents and young adults, typically before age 26, to prevent cervical and other cancers.
C. Herpes zoster (shingles) vaccine is recommended for older adults, usually starting at age 50 or 60, to reduce the risk of shingles and its complications.
D. DTaP is given to infants and young children. Instead, older adults should receive a Td or Tdap booster every 10 years.
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