A nurse is caring for a client with a chest tube. Which action should the nurse take?
Position the collection device below the level of the chest.
Clamp the tube when providing care activities.
Apply an occlusive dressing over the chest tube site.
Empty the chest tube collection chamber every shift.
The Correct Answer is A
Choice A reason: Positioning the collection device below the level of the chest is crucial to ensure proper drainage of air or fluid from the pleural space. This positioning uses gravity to facilitate drainage and prevent backflow into the pleural cavity, which could lead to complications such as pneumothorax or pleural effusion. The collection device should always be kept below the chest level to maintain effective drainage.
Choice B reason: Clamping the chest tube is generally not recommended unless specifically ordered by a physician or during certain procedures. Clamping can lead to a buildup of air or fluid in the pleural space, increasing the risk of tension pneumothorax. It is essential to keep the chest tube unclamped to allow continuous drainage and prevent complications.
Choice C reason: Applying an occlusive dressing over the chest tube site is necessary to prevent air from entering the pleural space and to secure the tube. However, this is not the primary action related to the positioning of the collection device. The occlusive dressing helps maintain the integrity of the chest tube insertion site and prevents infection.
Choice D reason: Emptying the chest tube collection chamber every shift is not a standard practice. The collection chamber should be monitored and emptied as needed based on the volume of drainage and the specific protocols of the healthcare facility. Regular monitoring is essential, but unnecessary emptying can disrupt the closed system and increase the risk of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1"]
Explanation
We know:
- The prescribed dose is 25 mg.
- The available concentration is 125 mg per 5 mL.
Step 2 is to set up the calculation.
We will use the formula: (Desired Dose in mL) = (Prescribed Dose in mg × Volume Available in mL) ÷ Concentration Available in mg
Step 3 is to plug in the values into the formula.
(Desired Dose in mL) = (25 mg × 5 mL) ÷ 125 mg
Step 4 is to perform the multiplication first.
25 mg × 5 mL = 125
Step 5 is to perform the division.
125 ÷ 125 mg = 1 mL
Step 6 is the result.
The nurse should administer 1 mL per dose.
Correct Answer is A
Explanation
Choice A reason: The glossopharyngeal nerve (CN IX) is primarily responsible for the gag reflex. It provides sensory input from the pharynx and posterior third of the tongue, which triggers the gag reflex when stimulated. This nerve plays a crucial role in swallowing and the reflexive action to prevent choking.
Choice B reason: The trigeminal nerve (CN V) is responsible for facial sensation and motor functions such as biting and chewing. It does not play a direct role in the gag reflex. While it is important for other sensory and motor functions, it is not involved in the reflex being assessed here.
Choice C reason: The vagus nerve (CN X) also contributes to the gag reflex by providing motor innervation to the muscles of the pharynx and larynx. However, the primary sensory input for the gag reflex comes from the glossopharyngeal nerve (CN IX). The vagus nerve works in conjunction with CN IX to complete the reflex action.
Choice D reason: The hypoglossal nerve (CN XII) controls the movements of the tongue. It is essential for speech and swallowing but does not have a role in the gag reflex. The hypoglossal nerve’s primary function is motor control of the tongue muscles.
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