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.

Answer and Explanation

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

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

A. A client who is displaying aggression: Using a gait belt on an aggressive client is unsafe because sudden movements or resistance could lead to injury for both the client and the caregiver. Aggressive behavior requires de-escalation strategies before considering physical assistance or mobility interventions like a gait belt.

B. A client who has had chest trauma: Gait belts should be avoided in clients with chest trauma because the pressure applied around the torso can exacerbate injuries such as rib fractures, pulmonary contusions, or other thoracic complications, posing significant health risks during mobilization.

C. A client who has limited arm strength: A gait belt is appropriate for clients with limited arm strength because it provides secure support around the waist without requiring the client to rely heavily on their upper limbs. It allows for safer ambulation and transfer by offering the caregiver a firm point of control.

D. A client who has a thoracic incision: Applying a gait belt over or near a thoracic incision can interfere with wound healing, cause pain, and increase the risk of wound dehiscence. Alternative methods for assisting mobility should be used for clients with fresh surgical sites in the thoracic region.

A. “If I have a health care proxy, then I do not need to have a living will” B. "My health care proxy designee is not able to sign a consent form on my behalf” C. “I do not need to name a relative as my designee in my health care proxy” D. "Once my health care proxy is in place, I relinquish my right to make my own decisions"

Correct Answer is C

Explanation

A. "If I have a health care proxy, then I do not need to have a living will.": A health care proxy and a living will serve different purposes. A living will outlines specific treatment preferences, while a health care proxy designates someone to make decisions. Having one does not eliminate the benefit or need for the other.

B. "My health care proxy designee is not able to sign a consent form on my behalf.": The designee named in a health care proxy is specifically authorized to make healthcare decisions, including signing consent forms, if the client becomes unable to do so themselves.

C. "I do not need to name a relative as my designee in my health care proxy.": A client can choose any competent adult they trust to act as their healthcare proxy; it does not have to be a relative. This flexibility allows clients to select someone they believe will best honor their wishes.

D. "Once my health care proxy is in place, I relinquish my right to make my own decisions.": Having a health care proxy does not remove the client's decision-making rights. The proxy only takes effect if the client becomes unable to make or communicate their own healthcare decisions.

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 pleural chest tube with a closed drainage system. Which of the following actions should the nurse recommend for the client's care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is assisting in planning care for a group of clients. For which of the following clients can the nurse safely gait belt?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client about advance directives and a health care proxy. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is assisting in the discharge planning of an infant who has a spica cast. Which of the following equipment needs should the nurse identify for discharge?

A nurse is discussing informed consent with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the information?

A nurse is collecting data from a child who is 1 hr postoperative following a tonsillectomy. Which of the following findings is the nurse's priority?

A nurse is reinforcing teaching with a client who has an electrolyte imbalance. Which of the following foods should the nurse include as the low in potassium?

A nurse in a long-term care facility is caring for an older adult client who has a history of hypertension. Which of the following findings should the nurse recognize is indicative of transient ischemic attacks?

The nurse has reviewed the Vital Signs at 1000. Which of the following statements should the nurse include when reinforcing teaching to the client following the procedure? Select all that apply.

A nurse at a provider's office is caring for a client. Select the 3 findings that require immediate follow-up.

A nurse is caring for a client who has toxoplasmosis and asks about the cause of the infection. Which of the following responses should the nurse make?