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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Explanation
A. Placement of a central venous catheter
Informed consent is a legal and ethical requirement that ensures clients have the necessary information to make autonomous decisions about their healthcare. The healthcare provider must obtain informed consent before performing any procedure that carries potential risks or benefits. Here's why the other options do not typically require informed consent:
Administration of an iron injection using Z-track technique in (option B) is not correct because, while informed consent may be required for administering certain medications or injections, the specific technique used, such as the Z-track technique, typically does not require separate informed consent. The Z-track technique is a method used to prevent leakage of the medication into subcutaneous tissues during injection.
Insertion of a nasogastric tube in (option C) is not correct because Insertion of a nasogastric tube is a common procedure performed to access the stomach or administer medications or nutrients. Informed consent is generally not required for nasogastric tube insertion as it is considered a routine procedure and is often included as part of the overall plan of care.
Irrigation of a wound with antibiotic solution in (option D) is not correct because wound irrigation is a standard procedure in wound care, and the use of an antibiotic solution may be part of the healthcare provider's prescribed treatment plan. Informed consent is typically not required for wound irrigation unless there are specific circumstances or risks associated with the procedure.
In summary, the nurse should identify that informed consent is required for A: Placement of a central venous catheter. This procedure involves the insertion of a catheter into a major blood vessel and carries potential risks and complications that require informed consent to ensure the client's understanding and agreement before proceeding
Correct Answer is C
Explanation
Insomnia refers to the difficulty in falling asleep or staying asleep, leading to sleep disturbances. It is a frequently reported symptom during the initial phase of nicotine withdrawal.
While weight loss can be associated with smoking cessation due to changes in metabolism, it is not a direct manifestation of nicotine withdrawal. Similarly, diarrhea is not a commonly reported symptom of nicotine withdrawal.
Diaphoresis, which refers to excessive sweating, can occur in some individuals during nicotine withdrawal, but it is not as commonly observed as insomnia. It is worth noting that different individuals may experience varying symptoms during nicotine withdrawal, and the intensity and duration of these symptoms can also differ.
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