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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Constipation is a common side effect of risperidone due to its anticholinergic effects. However, it is not the priority because it is not immediately life-threatening.
B. Visual disturbances can occur with risperidone, but they are not as urgent as cardiovascular abnormalities.
C. Dry mouth is another anticholinergic side effect, but it is not a priority concern compared to an irregular pulse.
D. Irregular pulse is the priority finding because risperidone can prolong the QT interval, increasing the risk of serious cardiac arrhythmias, including torsades de pointes, which can be life-threatening. Therefore, this finding should be reported to the provider immediately.
Correct Answer is C
Explanation
A. A bologna sandwich on rye bread. This is incorrect because rye bread contains gluten, which must be avoided in a celiac disease diet.
B. Whole wheat pasta with shrimp. This is incorrect because whole wheat pasta contains gluten, making it unsuitable for a child with celiac disease.
C. A corn tortilla with black beans. This is correct because corn tortillas are naturally gluten-free, and black beans provide a nutritious, safe option for a child with celiac disease.
D. Low sodium vegetable soup with barley. This is incorrect because barley contains gluten, making it inappropriate for a celiac-friendly diet.
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