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?
Ensure the device is kept below the level of the client's chest.
Clamp the chest tube every 4 hr.
Place the client in a supine position.
Empty the collection chamber every 8 hr.
The Correct Answer is A
Ensuring the device is kept below the level of the client's chest is important to ensure that the drainage system functions properly by allowing the fluid and air to flow downhill. Placing the device below the level of the chest helps facilitate gravity drainage.
Continuous suction is required for proper functioning of the chest tube drainage system. Clamping the chest tube can disrupt the suction and impede the removal of air or fluid from the pleural space. Only in specific circumstances, such as when changing the drainage system or assessing for air leaks, may the healthcare provider request a temporary clamping of the chest tube.
Positioning the client semi-Fowler's, with the head of the bed elevated, can help promote lung expansion and improve oxygenation. The specific positioning may vary depending on the client's condition and the healthcare provider's recommendations.
The nurse should empty the collection chamber as per the facility's protocol, which typically includes monitoring the drainage and emptying it when it reaches a certain level. Regular emptying of the collection chamber helps maintain proper functioning of the chest tube system and allows for accurate measurement of drainage output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Fluid overload refers to an excess volume of fluid in the body, which can occur as a result of various factors, including excessive fluid intake or inadequate fluid removal. Crackles heard in the lungs, also known as rales, can indicate fluid accumulation in the lungs, a condition known as pulmonary edema. It is a common manifestation of fluid overload and can be detected through auscultation of the lungs.
Weight loss is typically associated with inadequate calorie or nutrient intake, rather than fluid overload.
Weight loss is typically associated with inadequate calorie or nutrient intake, rather than fluid overload.
Weight loss is typically associated with inadequate calorie or nutrient intake, rather than fluid overload.
Correct Answer is B
Explanation
Explanation
B.Hypertension
Tranylcypromine is a monoamine oxidase inhibitor (MAOI) used to treat depression. One of the potential adverse effects of MAOIs is hypertensive crisis, which can be triggered by the consumption of foods high in tyramine. Tyramine-rich foods, such as aged cheeses, cured meats, certain wines, and fermented products, can cause the release of norepinephrine, leading to a sudden increase in blood pressure.
Monitoring the client for hypertension is crucial because a hypertensive crisis can be life-threatening. Signs and symptoms of hypertensive crisis may include severe headache, chest pain, palpitations, blurred vision, anxiety, and shortness of breath. If these symptoms occur, immediate medical intervention is required.
The other options are not specifically associated with the adverse effects of tranylcypromine:
Hyperglycemia in (option A) is not typically associated with tranylcypromine. However, it is important to monitor blood glucose levels in clients with pre-existing diabetes, as tranylcypromine can affect blood sugar control.
Hematuria (blood in the urine) in (option C) is not a common adverse effect of tranylcypromine.
Tinnitus (ringing in the ears) in (option D) is not a commonly reported adverse effect of tranylcypromine.
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