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 A
Explanation
Avoid quoting client comments when documenting: This is the correct action to take. When documenting client care, it is important to use objective language and avoid directly quoting client comments. Instead, the nurse should summarize or paraphrase the client's statements using professional and objective language.
Incorrect:
B- Limit documentation to subjective information: This is an incorrect action to take.
Documentation should include both subjective and objective information. Subjective information refers to the client's own experiences, perceptions, and feelings, while objective information refers to measurable and observable data.
C- Document giving a dose of pain medication just prior to administration: This is an incorrect action to take. Documentation should accurately reflect the timing and administration of medications. Documenting giving a dose of pain medication just prior to administration would be inaccurate and could lead to confusion and potential medication errors.
D- Document information telephoned in by a nurse who left the unit for the day: This is an incorrect action to take. Documentation should only include information that the nurse personally witnesses, assesses, or performs. Information provided by another nurse should be documented as a report or handoff communication rather than direct documentation.
Correct Answer is B
Explanation
Informed consent is a process where the healthcare provider explains the risks, benefits, and alternatives of a proposed procedure or treatment to the client. The client then demonstrates their understanding of this information and voluntarily agrees to undergo the procedure or treatment.
A. "I will have a large scar on my stomach after this procedure". This is incorrect for a vaginal hysterectomy, which does not involve an abdominal incision.
B. 'I am thankful I am done having children." This statement reflects an understanding of a key consequence of a hysterectomy, which is the removal of the uterus and the resulting inability to have children. This indicates that the client is aware of and accepts the major impact of the surgery on their reproductive capabilities.
C."I should expect my periods to resume in 1 month.": This is incorrect because the removal of the uterus means the client will no longer have menstrual periods.
D."I will no longer need a regular gynecological examination.": This is incorrect because regular gynecological examinations are still necessary to monitor overall reproductive health and screen for other conditions.
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