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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A Reason:

Retrieving the blood from the laboratory and running each unit at an 8-hour rate is not appropriate. According to transfusion guidelines, blood products should be infused within 4 hours to prevent bacterial growth and reduce the risk of transfusion-related complications1. Infusing blood over 8 hours increases the risk of these complications.

Choice B Reason:

Notifying the laboratory to split the unit into 2 and then infusing each half for 4 hours is also not ideal. While this approach might seem to address the time constraint, it is not a standard practice and could lead to issues with blood product integrity and patient safety2. Blood products are typically not split unless there are specific protocols in place, and this is not a common intervention for managing infusion rates.

Choice C Reason:

Calling the HCP to question the order is the correct intervention. Blood transfusions must be completed within 4 hours to ensure patient safety and maintain the integrity of the blood product3. The nurse should advocate for the patient by questioning any orders that do not align with established guidelines and best practices.

Choice D Reason:

Infusing each unit for 8 hours is incorrect. The maximum duration for infusing a unit of blood is 4 hours4. Extending the infusion time beyond this limit increases the risk of complications such as bacterial contamination and reduced efficacy of the blood product.

A. A nurse is educating a client about supplements that are effective for nausea. Which supplement should the nurse include? B. Ask the client to clench their teeth. C. Ask the client to read a Snellen chart. D. Ask the client to raise his eyebrows.

Correct Answer is B

Explanation

Choice A Reason:

Listening to the client’s speech is not a method used to assess cranial nerve V. This method is more relevant for assessing cranial nerves IX (Glossopharyngeal) and X (Vagus), which are involved in speech and swallowing.

Choice B Reason:

Clenching the teeth is a method used to assess the motor function of cranial nerve V (the trigeminal nerve). The trigeminal nerve is responsible for the movement of the muscles involved in chewing. When a client clenches their teeth, the nurse can palpate the masseter and temporal muscles to check for strength and symmetry. This helps determine if there are any abnormalities in the motor function of the trigeminal nerve.

Choice C Reason:

Asking the client to read a Snellen chart is a method used to assess cranial nerve II (Optic), which is responsible for vision. This method does not assess cranial nerve V.

Choice D Reason:

Asking the client to raise his eyebrows is a method used to assess cranial nerve VII (Facial), which controls facial expressions. This method is not used to assess cranial nerve V.

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A nurse is caring for a client with a chest tube. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is assessing a client’s cranial nerves. Which methods should the nurse use to assess cranial nerve V?

Correct Answer is B

Explanation

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