A nurse is contributing to the plan of care for a client who has a pleural chest tube with a closed drainage system. Which of the following actions should the nurse recommend for the client's care?
Maintain 30 ml sterile water in the drainage collection chamber
Place the drainage device level with the tube insertion site
Keep system tubing connections taped together.
Empty the drainage collection chamber every 4 hr.
The Correct Answer is C
A. Maintain 30 ml sterile water in the drainage collection chamber: The sterile water is maintained in the water-seal chamber, not the drainage collection chamber. The water-seal chamber typically holds about 2 cm of water to create a one-way valve preventing air from entering the pleural space, not 30 mL in the drainage area.
B. Place the drainage device level with the tube insertion site: The drainage device should always be kept below the level of the chest tube insertion site to allow gravity to assist drainage and to prevent backflow of fluid or air into the pleural cavity, which could cause complications.
C. Keep system tubing connections taped together: Taping the system tubing connections securely helps maintain a closed system, preventing accidental disconnections that could lead to air leaks or loss of the negative pressure needed for proper lung re-expansion. This is essential for the effectiveness of chest tube management.
D. Empty the drainage collection chamber every 4 hr: The drainage collection chamber is not emptied routinely. Instead, it is replaced when full or according to facility protocol. Frequent opening of the system increases the risk of introducing infection or losing the closed negative-pressure system.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Gloves: Gloves are important for contact precautions but are not sufficient protection against airborne infections like tuberculosis. Tuberculosis spreads through respiratory droplets that remain suspended in the air, requiring specialized respiratory protection.
B. Gown: A gown is generally used when there is a risk of direct contact with infectious material. While gowns are important for many isolation precautions, they do not protect against airborne transmission of tuberculosis.
C. Dosimeter badge: A dosimeter badge measures exposure to radiation, not infectious agents. It is used in environments with radiologic procedures and is unrelated to protecting against infectious diseases like tuberculosis.
D. N95 respirator: An N95 respirator is specifically designed to filter airborne particles, including Mycobacterium tuberculosis. It fits tightly around the face and provides the necessary protection against inhaling infectious airborne pathogens in the client’s environment.
Correct Answer is D
Explanation
A. Difficulty swallowing: Difficulty swallowing, or dysphagia, is not typically a direct indicator of unrelieved pain. It could suggest neurological or throat-related issues rather than being a primary symptom associated with inadequate pain control.
B. Constipation: Constipation is a common postoperative complication, often related to anesthesia, immobility, or opioid use. While it is important to address, it does not directly reflect the client's current pain level or effectiveness of pain management.
C. Urinary retention: Urinary retention can occur due to anesthesia effects, pelvic surgery, or opioid administration. Although it is a significant postoperative concern, it is not a reliable or direct indicator of unrelieved pain.
D. Restlessness: Restlessness is a common sign of unrelieved pain, particularly in postoperative clients. When clients are uncomfortable or in significant pain, they may appear restless, anxious, or unable to remain still, signaling the need for further pain assessment and intervention.
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