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 A
Explanation
Choice A Reason:
Sclera is correct. The sclera, or the white part of the eye, is a reliable site to assess for jaundice, especially in dark-skinned individuals. Jaundice causes a yellowish discoloration of the sclera due to the accumulation of bilirubin in the blood. This yellowing is often more noticeable in the sclera than in other parts of the body.
Choice B Reason:
Dorsal surface of the foot is incorrect. The dorsal surface of the foot is not a reliable site for assessing jaundice, particularly in dark-skinned individuals. The skin on the feet may not show the yellow discoloration as clearly as the sclera.
Choice C Reason:
Pinnae of the ears is incorrect. The pinnae, or outer parts of the ears, are not typically used to assess for jaundice. The skin in this area may not show the yellow discoloration as effectively as the sclera.
Choice D Reason:
Palmar surface of the hand is incorrect. While the palms can sometimes show signs of jaundice, they are not as reliable as the sclera. The yellow discoloration may be less noticeable on the palms, especially in dark-skinned individuals.
Correct Answer is A
Explanation
Choice A Reason:
Fiber is correct. Fiber is essential for maintaining healthy bowel elimination. It helps to add bulk to the stool and promotes regular bowel movements. There are two types of fiber: soluble and insoluble. Soluble fiber absorbs water and forms a gel-like substance, which helps soften the stool and make it easier to pass. Insoluble fiber adds bulk to the stool and helps it move through the digestive tract more quickly.
Choice B Reason:
Fat is incorrect. While fats are an important part of a balanced diet, they do not play a primary role in maintaining healthy bowel elimination. Fats are essential for energy and the absorption of fat-soluble vitamins, but they do not have the same effect on bowel movements as fiber.
Choice C Reason:
Protein is incorrect. Protein is crucial for building and repairing tissues, but it does not directly influence bowel elimination. A diet high in protein without adequate fiber can sometimes lead to constipation.
Choice D Reason:
Minerals are incorrect. Minerals are vital for various bodily functions, including bone health, fluid balance, and muscle function. However, they do not directly impact bowel elimination in the same way that fiber does.
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