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 A
Explanation
Rationale:
A. Increased urinary output: Diuresis is expected within the first 12 to 24 hours postpartum as the body eliminates excess fluid retained during pregnancy. Increased urinary output helps reduce blood volume and interstitial fluid accumulated during gestation, making this a normal finding.
B. Temperature 38.2° C (100.0° F): A slight elevation in temperature can occur postpartum due to dehydration or breast engorgement, but 38.2°C is at the upper limit and may suggest infection if persistent. Therefore, it should be monitored rather than considered a typical finding.
C. Presence of lochia serosa: At 12 hours postpartum, lochia rubra, which is bright red and contains blood and tissue debris, is expected. Lochia serosa, which is pink or brown and more serous, typically appears around day 4 postpartum.
D. Deep tendon reflexes 3+: Reflexes of 3+ are slightly brisker than normal and may indicate neurological irritability or preeclampsia if seen with other symptoms. A normal postpartum reflex should be 2+, so this finding requires further evaluation.
Correct Answer is ["B","C","D"]
Explanation
Rationale
• Ensure the transfusion tubing is flushed with dextrose 5% in water: Flushing with D5W can cause hemolysis due to the hypotonicity and sugar content, leading to clumping or damage to red blood cells. Normal saline is the only acceptable fluid for flushing or administering with blood products to maintain cell integrity and avoid adverse reactions.
• Obtain a large-bore IV catheter: A large-bore catheter, typically 18–20 gauge, is necessary to allow rapid infusion of blood and reduce the risk of hemolysis. It also minimizes resistance and facilitates effective delivery during emergencies like hypovolemic shock from GI bleeding.
• Witness the client signing a consent for transfusion: Informed consent is a legal and ethical requirement prior to initiating a transfusion. The nurse must ensure that the client understands the purpose, benefits, and risks of the procedure, and the nurse may witness the client’s signature.
• Ensure two nurses confirm the information on the blood label: Verifying the client's identity and blood product information by two licensed personnel prevents transfusion errors, such as ABO incompatibility. This is a critical safety measure and a standard facility protocol before starting the transfusion.
• Explain to the client that transfusion reactions are not serious: Minimizing the risks of transfusion reactions is misleading and unsafe. Some reactions can be life-threatening, such as hemolytic or anaphylactic reactions. The nurse should provide accurate education about potential signs and encourage prompt reporting.
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