A nurse is planning care for a client who has a chest tube. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

Clamp the chest tube every 2 hr to assess the amount of drainage.

Maintain the collection chamber above the level of the client's waist.

Strip the chest tube vigorously to dislodge blood clots.

Add water to the water seal chamber as it evaporates.

Mark the drainage output on the collection chamber.

Answer and Explanation

Correct Answer : D,E

Rationale:
A. Clamp the chest tube every 2 hr to assess the amount of drainage: Routine clamping of a chest tube is unsafe because it can cause a sudden buildup of pressure in the pleural space, leading to a tension pneumothorax.

B. Maintain the collection chamber above the level of the client's waist: The collection chamber should always be positioned below the level of the client’s chest to allow gravity drainage. Placing it above the waist would prevent proper drainage.

C. Strip the chest tube vigorously to dislodge blood clots: Vigorous stripping or milking of the chest tube can create excessive negative pressure, potentially damaging lung tissue. Current guidelines recommend gentle milking only if ordered and rarely if obstruction is suspected.

D. Add water to the water seal chamber as it evaporates: Maintaining the proper water level in the water seal chamber is essential to preserve the one-way valve function that prevents air from re-entering the pleural space. Evaporation can reduce the seal, so the nurse should routinely check and refill it.

E. Mark the drainage output on the collection chamber: Documenting drainage at regular intervals allows accurate monitoring of the client’s progress and early identification of complications such as increased bleeding or fluid accumulation. It supports timely communication with the healthcare provider.

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Correct Answer is ["A","B","F"]

Explanation

Rationale:
A. Elevate the affected forearm with pillows: Elevation helps reduce swelling and promotes venous return, which is critical in the immediate management of a fracture to prevent complications such as increased edema or impaired circulation.

B. Administer Ibuprofen 200 mg PO: The child reports pain at a level of 5, meeting the prescription threshold. Administering analgesia promptly helps manage discomfort and supports cooperation with further interventions, such as casting.

C. Place a nonadherent dressing on the right knee abrasion: While wound care is important, the abrasion is minor and not the most urgent concern. Prioritization focuses on the fractured limb and pain management.

D. Review cast care instructions with the child's parents: Education is important but is not the immediate priority before the cast is applied. It can be provided after the child is stabilized and pain is managed.

E. Explain the cast application procedure to the child: While preparing the child psychologically is important, immediate interventions to reduce pain and swelling take precedence over anticipatory teaching.

F. Apply ice packs to the fingers and along the right forearm: Ice helps reduce swelling and pain in the acute phase of the fracture. Applying ice in combination with elevation supports circulation and comfort while awaiting casting.

A. "I will take a bulk-forming laxative every day." B. "I will avoid strenuous exercise." C. "I will increase my intake of high-fiber foods." D. "I will limit my fluid intake to 1 liter per day."

Correct Answer is C

Explanation

Rationale:
A. "I will take a bulk-forming laxative every day.": While bulk-forming laxatives can help manage constipation, taking them without adequate fluid intake can worsen constipation or cause bowel obstruction. Education should emphasize combining fiber with sufficient fluids.

B. "I will avoid strenuous exercise.": Regular physical activity actually promotes intestinal motility and helps prevent opioid-induced constipation. Avoiding exercise would counteract this preventive strategy.

C. "I will increase my intake of high-fiber foods.": Consuming high-fiber foods, such as fruits, vegetables, and whole grains, adds bulk to stool and promotes regular bowel movements. This is a key dietary intervention for preventing constipation in clients taking opioids like oxycodone.

D. "I will limit my fluid intake to 1 liter per day.": Limiting fluids can exacerbate constipation because hydration is necessary to soften stool and support normal bowel function. Clients should maintain adequate fluid intake alongside increased dietary fiber.

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A nurse is planning care for a client who has a chest tube. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","F"]

Explanation

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Correct Answer is C

Explanation

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