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.

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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Correct Answer is D

Explanation

A. Shake both insulin vials for 2 min before withdrawing the doses. Insulin vials should never be shaken, as this can create air bubbles and affect dosage accuracy. NPH insulin should be gently rolled between the hands to mix.
B. Administer the mixture within 5 min of preparing it. While insulin should be administered promptly, there is no strict 5-minute requirement.
C. Withdraw the NPH insulin before the regular insulin. Regular insulin should be drawn up first to prevent contamination with the cloudy NPH insulin.
D. Inject air into the regular insulin vial before injecting air into the NPH vial. Air should be injected into the regular insulin first, then into the NPH insulin vial, before withdrawing the doses in the correct order.

A. A bologna sandwich on rye bread B. Whole wheat pasta with shrimp C. A corn tortilla with black beans D. Low sodium vegetable soup with barley

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

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Naxlex Comprehensive Predictor Exams

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