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:

A pureed diet consists of foods that are blended to a smooth consistency. This type of diet is typically recommended for clients who have severe swallowing difficulties or are at risk of aspiration. While it can be easier to consume for those with significant dental issues, it may not provide the variety and texture that a mechanical soft diet offers, which can be more satisfying and nutritionally adequate for someone with multiple cavities and missing teeth.

Choice B Reason:

A soft diet includes foods that are easy to chew and swallow but are not necessarily blended or pureed. This diet is often recommended for clients recovering from surgery or those with mild chewing difficulties. However, for a client with multiple cavities, chipped, and missing teeth, a soft diet might still pose challenges in terms of chewing and could lead to discomfort or inadequate nutrition.

Choice C Reason:

A mechanical soft diet is specifically designed for individuals who have difficulty chewing but do not require pureed foods. This diet includes foods that are easy to chew and swallow, such as ground meats, cooked vegetables, and soft fruits. It provides a balance of texture and nutrition, making it the most appropriate choice for a client with multiple cavities, chipped, and missing teeth. This diet helps ensure the client can eat comfortably and maintain adequate nutrition.

A. 380 mL B. 550 mL C. 600 mL D. 720 mL

Correct Answer is A

Explanation

Choice A Reason:

A 24-hour urinary output of 380 mL indicates oliguria. Oliguria is defined as a urine output of less than 400-500 mL per day in adults. This condition can be caused by various factors, including dehydration, kidney dysfunction, or postoperative complications. Monitoring urine output is crucial for assessing kidney function and overall fluid balance, especially after major surgeries like a colon resection.

Choice B Reason:

A 24-hour urinary output of 550 mL is slightly above the threshold for oliguria. While it is still relatively low, it does not meet the strict criteria for oliguria, which is typically defined as less than 400-500 mL per day. This output suggests that the client is producing an adequate amount of urine, though it may still warrant close monitoring to ensure it does not decrease further.

Choice C Reason:

A 24-hour urinary output of 600 mL is within the normal range and does not indicate oliguria. Normal urine output for adults is generally considered to be around 800-2000 mL per day, depending on fluid intake and other factors. This output suggests that the client’s kidneys are functioning properly and that there is no immediate concern for oliguria.

Choice D Reason:

A 24-hour urinary output of 720 mL is also within the normal range and does not indicate oliguria. This output is closer to the lower end of the normal range but still suggests adequate kidney function. It is important to continue monitoring the client’s urine output to ensure it remains within a healthy range, especially after surgery.

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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

Edited TextA nurse is auditing a client. During the assessment, the nurse notes the client has multiple cavities, chipped, and missing teeth. The client reports having difficulty eating. Which diet should the nurse recommend the primary health care provider to order for this client?

Correct Answer is C

Explanation

A nurse is monitoring the urinary output of a client who had a colon resection. Which 24-hour output total indicates oliguria?

Correct Answer is A

Explanation

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