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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Chlorhexidine: Chlorhexidine is primarily used as an antiseptic for skin preparation or wound cleaning. It is not effective for disinfecting surfaces contaminated with bloodborne pathogens such as HIV.
B. Hydrogen peroxide: While hydrogen peroxide has disinfectant properties, it is less effective than bleach against a broad range of viruses, especially in situations involving blood spills where a higher-level disinfectant is recommended.
C. Bleach: A 1:10 dilution of household bleach (sodium hypochlorite) is the recommended solution for disinfecting surfaces contaminated with blood due to its strong virucidal properties. It effectively kills HIV and other bloodborne pathogens on environmental surfaces.
D. Isopropyl alcohol: Isopropyl alcohol has limited effectiveness against organic matter like blood and is not recommended for disinfecting blood-contaminated surfaces. It evaporates quickly and may not provide adequate contact time for complete disinfection.
Correct Answer is D
Explanation
Rationale:
A. Start using a highchair for feedings: Infants typically begin using a highchair around 6 months of age when they can sit unsupported. At 3 months, using a highchair is unsafe as the infant lacks sufficient head and trunk control.
B. Place no more than one small pillow in the crib: Pillows and soft bedding increase the risk of suffocation and sudden infant death syndrome (SIDS). The safest practice is to keep the crib free of pillows, blankets, and other soft items.
C. Make sure the crib mattress is soft: A firm crib mattress is recommended to reduce the risk of suffocation and SIDS. A soft mattress can create indentations that pose hazards for infants.
D. Remove bibs when the infant is going to sleep: Bibs can become choking or strangulation hazards during sleep. Removing them before sleep reduces the risk of airway obstruction and promotes infant safety.
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