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.

Answer and Explanation

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.

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Correct Answer is ["C","D"]

Explanation

Rationale:

• Past medical history like Parkinson’s disease increases the risk of delirium but is not a direct symptom. It may contribute but does not confirm the presence of delirium alone. Current behavior and cognition changes are more reliable indicators.

• Illusions involve misinterpreting real stimuli, unlike this client’s perception of spiders that aren’t there. Hallucinations are a more accurate description of this experience. Therefore, illusions are less consistent with the actual findings.

• Change in orientation is a hallmark of delirium and is shown by the client’s confusion about the date and location. The sudden onset and fluctuation in awareness suggest an acute cognitive disturbance. This finding supports the development of delirium in the ICU setting.

• Hallucinations, such as seeing spiders that are not present, reflect sensory misperceptions. These are typical in hyperactive delirium and often cause agitation or fear. They indicate an altered mental state requiring urgent assessment.

A. The client's next dressing change is scheduled in 4 hr. B. The client has developed difficulty ambulating C. The client's vital signs are checked every 8 hr. D. The client has state-sponsored health insurance.

Correct Answer is B

Explanation

Rationale:

A. The client's next dressing change is scheduled in 4 hr.: This is routine scheduling information that does not require input from the entire interprofessional team. It is more relevant for shift handoff or task tracking than for collaborative care planning.

B. The client has developed difficulty ambulating: New or worsening mobility issues can impact the client’s safety, rehabilitation needs, discharge planning, and therapy referrals. This information is essential for all members of the interprofessional team, including physical therapists and case managers.

C. The client's vital signs are checked every 8 hr.: This detail reflects standard monitoring protocol and does not provide meaningful insight into the client’s current health status or changes that would impact team planning or intervention.

D. The client has state-sponsored health insurance: While insurance type may influence discharge or equipment planning, it is handled by social services or case management. It is not the most relevant information to bring forward in a clinical team meeting.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["C","D"]

Explanation

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Correct Answer is B

Explanation

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