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 {"dropdown-group-1":"E","dropdown-group-2":"E"}
Explanation
The nurse should prepare to administer naloxone and oxygen by face mask 10 L/min.
Rationale:
- Naloxone is used to reverse opioid-induced respiratory depression, which is a potential risk during moderate sedation.
- Oxygen by face mask 10 L/min is necessary to maintain adequate oxygenation during and after sedation, as respiratory depression can occur.
- Acetaminophen is not used for immediate management of sedation-related complications.
- An additional dose of fentanyl or propofol would deepen sedation, not manage its complications.
- Propranolol is a beta-blocker that is not indicated in this situation.
Correct Answer is D
Explanation
A. Keep the urinary bag at bladder level when ambulating. This is incorrect because the collection bag should always be kept below the bladder level to prevent backflow of urine, which can increase the risk of infection.
B. Loop the tubing so that it is lower than the collection bag. This is incorrect because kinking or looping the tubing can obstruct urine flow, leading to stasis and increasing the risk of bacterial growth and infection.
C. Obtain urinary samples by disconnecting the tubing connections. This is incorrect because disconnecting the system increases the risk of introducing bacteria. A sample should be obtained from the designated port using aseptic technique.
D. Secure the catheter to the client's thigh. This is correct because securing the catheter reduces movement and prevents urethral trauma, which lowers the risk of infection.
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