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A nurse is caring for a client who has a three-chamber chest tube system. Which of the following actions should the nurse take?

A.

Ensure 2 cm (0.8 in) of water is in the water seal chamber.

B.

Check the patency of the tubing every 2 hr.

C.

Keep the drainage system above the level of the client's chest.

D.

Empty the collection chamber every 8 hr.

Answer and Explanation

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 {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Essential Interventions:

  • Monitor fetal heart rate
  • Administer ampicillin IV
  • Place client in left lateral position
  • Request a prescription for ephedrine

Contraindicated Intervention:

  • Decrease the IV flow rate

Rationale:

  • Monitor fetal heart rate (Essential): Epidural anesthesia can cause maternal hypotension, leading to decreased uteroplacental perfusion. Continuous fetal heart rate monitoring ensures the fetus is tolerating labor well.
  • Administer ampicillin IV (Essential): The client tested positive for Group B Streptococcus (GBS) at 37 weeks, requiring prophylactic IV antibiotic administration during labor to prevent neonatal infection.
  • Place client in left lateral position (Essential): This position improves venous return, enhances placental perfusion, and prevents hypotension caused by epidural anesthesia.
  • Request a prescription for ephedrine (Essential): Epidural anesthesia can cause maternal hypotension, and ephedrine is a vasopressor that can help restore blood pressure if needed.
  • Decrease the IV flow rate (Contraindicated): IV fluids should be maintained or increased to prevent hypotension, a common side effect of epidural anesthesia. Reducing the IV rate could exacerbate hypotension and fetal distress.

Correct Answer is B

Explanation

A. Hypertension is not a typical finding of hypocalcemia. Instead, hypocalcemia can cause hypotension due to decreased myocardial contractility.
B. Muscle twitching is a common manifestation of hypocalcemia. Low calcium levels increase neuromuscular excitability, leading to twitching, tetany, and spasms.
C. A bounding pulse is not associated with hypocalcemia. Instead, hypocalcemia can cause weak, thready pulses due to decreased cardiac output.
D. Increased urine output is not a direct symptom of hypocalcemia. However, hypercalcemia can lead to polyuria due to its effect on the kidneys.

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