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
Explanation
C. I will wear a clean pair of cotton socks each day
Wearing a clean pair of cotton socks each day is an important aspect of foot care for individuals with diabetes. Here's why the other options are incorrect:
Using iodine to disinfect cuts on the feet in (option A) is not recommended for individuals with diabetes as it can be irritating to the skin and delay wound healing. It is best to clean cuts with mild soap and water and consult a healthcare professional for proper wound care.
Soaking feet in warm water every morning in (option B) is not recommended for individuals with diabetes. Prolonged exposure to water can increase the risk of dryness and cracking, leading to skin breakdown and infections. It is advisable to avoid prolonged soaking and to dry the feet thoroughly after washing.
Removing ingrown toenails at home in (option D) is not recommended for individuals with diabetes. Attempting to do so can result in injury and increase the risk of infection. It is important for individuals with diabetes to seek professional care for any foot-related concerns, including ingrown toenails.
In summary, the correct statement is C: "I will wear a clean pair of cotton socks each day." This demonstrates an understanding of the importance of foot hygiene and minimizing moisture to reduce the risk of fungal infections and foot complications for individuals with diabetes.
Correct Answer is ["A","C","D"]
Explanation
Correct:
A. Creating a stimulating environment helps engage the client and can reduce restlessness and agitation. This can include activities, social interactions, and sensory stimulation tailored to the individual's preferences.
C. Clients with Alzheimer's disease may become overwhelmed and have difficulty making decisions when presented with too many options. By limiting choices, caregivers can help reduce confusion and frustration for the client.
D. Clients with Alzheimer's disease may experience memory impairment and difficulty with orientation. Using written signs can help them navigate their surroundings and locate essential areas, such as the bathroom. Clear and simple signs can be helpful for maintaining independence and minimizing confusion.
incorrect:
B. Confrontation, which involves challenging or arguing with the client, can escalate agitation and distress. Instead, caregivers should use techniques such as redirection, validation, and providing a calm and supportive environment to manage challenging behaviors associated with Alzheimer's disease.
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