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 A

Explanation

Choice A Reason:

Use good body mechanics is correct. Good body mechanics involve using the body in an efficient and careful way to prevent injury. This includes bending at the knees instead of the waist, keeping the back straight, and using the legs to lift heavy objects. Proper body mechanics reduce the strain on the back and joints, preventing injuries.

Choice B Reason:

Maintain proper posture is also important but is part of using good body mechanics. Proper posture involves keeping the spine in a neutral position, avoiding slouching, and ensuring that the head is aligned with the spine. This helps distribute weight evenly and reduces the risk of injury.

Choice C Reason:

Use assistive devices is correct. Assistive devices such as transfer boards, mechanical lifts, and gait belts can help reduce the physical strain on nurses when moving or lifting patients. These devices are designed to make tasks safer and easier, thereby minimizing the risk of back and joint injuries.

Choice D Reason:

Stay physically fit is also important. Physical fitness helps maintain muscle strength, flexibility, and endurance, which are crucial for performing physically demanding tasks. Regular exercise can help prevent injuries by improving overall body mechanics and reducing fatigue.

A. The pads will keep the staff from workplace injuries such as a pulled muscle. B. The pads will absorb any urinary incontinence and contain stool. C. The pads will help prevent friction and shearing when repositioning the client. D. The pads will prevent the client from being diaphoretic.

Correct Answer is C

Explanation

Choice A reason: While lift pads can help reduce the risk of workplace injuries for staff, such as pulled muscles, this is not their primary purpose. The main goal of using lift pads is to protect the client from injury during repositioning. Lift pads distribute the client’s weight more evenly, making it easier for staff to move them without straining themselves.

Choice B reason: Lift pads are not designed to absorb urinary incontinence or contain stool. There are specific products like incontinence pads and briefs for managing urinary and fecal incontinence. Lift pads are primarily used to assist with the safe repositioning of immobile clients.

Choice C reason: The primary purpose of lift pads is to help prevent friction and shearing when repositioning the client. Friction and shearing can cause skin damage and pressure ulcers, especially in immobile clients. Lift pads reduce the risk of these injuries by allowing smoother and safer movements.

Choice D reason: Lift pads do not prevent clients from being diaphoretic (sweating excessively). Diaphoresis can be managed through other means, such as adjusting room temperature, using fans, or providing appropriate clothing and bedding. Lift pads are not intended for this purpose.

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

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Correct Answer is C

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