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 D
Explanation
A. Varicella vaccine is given at 12–15 months and a second dose at 4–6 years. It is not given at 2 months.
B. Influenza vaccine is recommended annually starting at 6 months of age. It is not given at 2 months.
C. Hepatitis A vaccine is given at 12–23 months, with a second dose 6 months later. It is not given at 2 months.
D. Rotavirus vaccine is routinely given at 2 months and again at 4 months (and possibly 6 months depending on the vaccine type). This is the correct answer.
Correct Answer is A
Explanation
A. "I can use chamomile tea to promote sleep." Chamomile has calming properties and is commonly used as a natural remedy to promote relaxation and improve sleep.
B. "Herbal medicines do not interact with conventional medications." Many herbs can interact with prescription medications, potentially causing harmful effects.
C. "I can use ginger to help treat headaches." Ginger is primarily used to reduce nausea and motion sickness rather than for headache relief.
D. "Herbal medicines are regulated by the Food and Drug Administration." Herbal supplements are not regulated by the FDA in the same way as prescription and over-the-counter medications.
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