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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:

A. Chlorhexidine: Chlorhexidine is primarily used as an antiseptic for skin preparation or wound cleaning. It is not effective for disinfecting surfaces contaminated with bloodborne pathogens such as HIV.

B. Hydrogen peroxide: While hydrogen peroxide has disinfectant properties, it is less effective than bleach against a broad range of viruses, especially in situations involving blood spills where a higher-level disinfectant is recommended.

C. Bleach: A 1:10 dilution of household bleach (sodium hypochlorite) is the recommended solution for disinfecting surfaces contaminated with blood due to its strong virucidal properties. It effectively kills HIV and other bloodborne pathogens on environmental surfaces.

D. Isopropyl alcohol: Isopropyl alcohol has limited effectiveness against organic matter like blood and is not recommended for disinfecting blood-contaminated surfaces. It evaporates quickly and may not provide adequate contact time for complete disinfection.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C","dropdown-group-3":"B"}

Explanation

Rationale:

Pneumonia: The child’s shallow respirations, diminished breath sounds at the bases, and ongoing refusal to use the incentive spirometer suggest decreased lung expansion and poor airway clearance. These are classic risk factors for postoperative pneumonia, especially in pediatric clients who are reluctant to engage in deep breathing exercises.
Peritonitis: Peritonitis would be indicated by signs such as a rigid abdomen, rebound tenderness, or marked fever. The client has mild abdominal tenderness but not the severity or systemic signs expected with peritonitis.
Wound infection: There are no signs of wound infection. The surgical dressing is consistently described as dry and intact with no redness, drainage, or swelling, which are typical indicators of infection.
Temperature: The child's temperature is slightly elevated but remains within the low-grade range and does not independently indicate a serious complication. It’s not the most significant factor in this case.
Bowel sounds: Hypoactive bowel sounds are expected after abdominal surgery and do not directly point to a respiratory complication. They are improving postoperatively and are not a primary concern for pneumonia.
Breathing effort: The child’s consistently shallow respirations and diminished breath sounds show a risk for poor ventilation. These are warning signs for the development of postoperative pneumonia.
Abdominal tenderness: Mild to moderate tenderness is expected 1 day after abdominal surgery and shows improvement over time. It is not strongly suggestive of a new or worsening condition like pneumonia.
Refusal to use incentive spirometer: Using the incentive spirometer encourages deep breathing and lung expansion. Refusing it increases the risk of atelectasis and subsequent pneumonia, especially in pediatric clients with shallow breathing patterns.
Surgical dressing: The dressing is consistently described as dry and intact with no signs of infection or complication. It does not point to any current or developing risk.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse is caring for a client who has AIDS. Which of the following solutions should the nurse use to disinfect the client's overbed table following a blood spill?

Correct Answer is C

Explanation

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C","dropdown-group-3":"B"}

Explanation

A nurse is preparing to insert a nasogastric tube in a client. Which of the following actions should the nurse take?

A nurse is assisting in the care of a client who is placed in wrist restraints. Which of the following should the nurse recognize as an expected finding?

A nurse is assisting with the care of a client whose partner died suddenly in a motor vehicle accident. The partner states, "If only I had another day with them." The nurse should identify the client is experiencing which of the following reactions to the loss?

The nurse is reviewing the client's medical record. Exhibits The nurse is assisting with the care of the client prior to a blood transfusion. Which of the following actions should the nurse take? Select all that apply.

A nurse is caring for a client who has a peanut allergy. The client states. "I feel like my throat is closing "Which of the following actions should the nurse take?

A nurse is contributing to the plan of care for a client who has major depressive disorder. Which of the following recommendations should the nurse include in the plan of care?

A nurse is planning care for four clients. Which of the following tasks should the nurse ask the charge nurse to reassign to an RN?

A nurse is preparing to delegate client care to an assistive personnel (AP). Which of the following information should the nurse verify prior to delegation?