A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?

Clamp the chest tube every 4 hr.

Place the client in a supine position.

Ensure the device is kept below the level of the client's chest.

Empty the collection chamber every 8 hr.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Clamp the chest tube every 4 hr: Routine clamping of a chest tube is not recommended, as it can lead to tension pneumothorax by trapping air in the pleural space. Clamping is only done briefly and for specific reasons, such as system checks or before removal.

B. Place the client in a supine position: The supine position can impair lung expansion and hinder drainage from the pleural space. Clients with a chest tube are best positioned in semi-Fowler’s or high-Fowler’s to promote ventilation and facilitate drainage.

C. Ensure the device is kept below the level of the client's chest: Keeping the drainage system below chest level promotes gravity-assisted drainage and prevents backflow of air or fluid into the pleural space, which could compromise lung re-expansion.

D. Empty the collection chamber every 8 hr: The collection chamber is not emptied; it is replaced when full. Opening the system introduces infection risk and disrupts the closed drainage system necessary for maintaining negative pressure.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

Rationale:

A. Tonic-clonic seizures: Tonic-clonic activity is induced during the ECT procedure itself but typically resolves within seconds. It is not expected to persist 15 minutes post-procedure, as seizure activity is carefully controlled and monitored during the treatment.

B. Sleep apnea: While general anesthesia used during ECT can cause brief respiratory depression, sleep apnea is not a typical or expected consequence of the procedure. Continuous monitoring ensures airway patency during and immediately after treatment.

C. Paresthesias: Numbness or tingling sensations (paresthesias) are not common side effects of ECT. The procedure affects brain activity and cognition rather than peripheral nerves, making this symptom unlikely post-treatment.

D. Disorientation: Temporary confusion or disorientation is a common and expected side effect shortly after ECT. It typically resolves within 30 to 60 minutes as the effects of anesthesia wear off, and it is routinely monitored during recovery.

A. Open the side flap of the sterile kit, allowing it to lie flat on the work surface B. Open the flap on the sterile kit nearest to the nurse and place the flap on the work surface. C. Apply sterile gloves. D. Open the outermost flap of the sterile kit away from the nurse's body.

Correct Answer is D

Explanation

Rationale:

A. Open the side flap of the sterile kit, allowing it to lie flat on the work surface: This step comes later in the process of opening a sterile field. Side flaps should be opened after the top (farthest) flap to prevent reaching over the sterile field and contaminating it.

B. Open the flap on the sterile kit nearest to the nurse and place the flap on the work surface: Opening the closest flap first risks contaminating the sterile field by reaching over it. This flap should be opened last, after the top and side flaps are already secured.

C. Apply sterile gloves: Sterile gloves are applied after the sterile field is prepared and all supplies are organized within the sterile area. Putting them on too early may lead to contamination during field setup.

D. Open the outermost flap of the sterile kit away from the nurse's body: The first step in establishing a sterile field is to open the flap away from the body. This minimizes contamination by preventing the nurse from leaning over the sterile surface.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder, which of the following findings should the nurse expect 15 min following the procedure?

Correct Answer is D

Explanation

A nurse is preparing to complete a sterile dressing change for a client's wound. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is caring for a client who has rheumatoid arthritis and is having difficulty with ADLs, such as cooking and eating. The nurse should ensure that the client has a referral to which of the following members of the interprofessional team?

A nurse is reinforcing teaching with a caregiver about how to safely prepare formula for their 3-day-old newborn. Which of the following statements should the nurse include in the teaching?

The nurse continues to assist in the care of the client. Exhibits Complete the following sentence by using the lists of options. The nurse should first ensure administration of the client's e to the client's dropdown due to the client’s dropdown.

A nurse is reinforcing teaching with an older adult client about home safety. Which of the following client statements indicates an understanding of the teaching?

A nurse is collecting data from a client who has a long leg cast on his left leg. Which of the following findings is the priority?

A nurse is caring for a client who was recently diagnosed with depression. The client's partner asks when he will get better. Which of the following is an appropriate response by the nurse?

A nurse is reinforcing teaching with the guardians of a 6-year-old child who has cystic fibrosis. Which of the following information should the nurse include in the teaching?

A nurse is assisting with the care of a client whose partner died suddenly in a motor vehicle accident. The partner states, "If only I had another day with them." The nurse should identify the client is experiencing which of the following reactions to the loss?