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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Related Questions
Correct Answer is B
Explanation
Splinting the incision with a pillow when changing positions can provide support and help minimize discomfort and pain in clients who have undergone a cesarean birth. It can help reduce strain on the incision site and provide a sense of stability and comfort.
"You can apply counterpressure to your back with each position change" may be helpful for managing back pain, but it does not specifically address the client's request for nonpharmacological interventions to manage pain when changing positions after a cesarean birth.
"You should change positions as little as possible" is not an appropriate response as it does not address the client's need to manage pain when changing positions. Encouraging movement and position changes, along with appropriate support, can aid in recovery and prevent complications such as blood clots and respiratory issues.
"You should use patterned-paced breathing when changing positions" is not specifically related to managing pain when changing positions after a cesarean birth. While breathing techniques can be useful for pain management during labor and certain procedures, it may not be the most effective strategy for managing pain when changing positions post-cesarean.
Correct Answer is D
Explanation
It is common for school-age children to exhibit magical thinking and believe that their actions or thoughts have the power to cause events, including the illness or death of a loved one. Therefore, it would be expected for the school-age brother of a child with terminal cancer to have thoughts or beliefs that his own behavior is causing his brother's death.
It is important for the nurse to provide age-appropriate education and support to help the brother understand the nature of the illness and address any misconceptions or feelings of guilt.
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