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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"}}
Explanation
Rationale:
• Deep tendon patellar reflex: The reflex response decreased from 4+ to 2+, demonstrating a reduction in hyperreflexia. This improvement indicates effective magnesium sulfate therapy, showing decreased neuromuscular irritability and a lower risk of progression to eclampsia.
• Blood pressure: The blood pressure declined from 166/110 mm Hg to 152/90 mm Hg, reflecting effective antihypertensive therapy and improved vascular tone. This moderate reduction suggests that labetalol and magnesium sulfate are successfully controlling severe preeclampsia symptoms.
• Heart rate: The heart rate remained within normal parameters (72–90/min) across both days, showing stable cardiac function without significant deviation. This consistency indicates no notable change in hemodynamic status related to treatment.
• Edema: The client continues to exhibit +3 pitting edema in both lower extremities, reflecting persistent fluid retention and endothelial dysfunction. This ongoing finding suggests that intravascular fluid shifts typical of preeclampsia have not yet resolved.
Correct Answer is A
Explanation
Rationale:
A. Potassium 3.1 mEq/L (3.5 to 5 mEq/L): Hypokalemia increases the risk of digoxin toxicity because low potassium levels enhance digoxin’s effects on the myocardium, potentially leading to arrhythmias and other toxic effects. Monitoring electrolytes is crucial for clients taking digoxin, especially when on diuretics like furosemide.
B. WBC count 12,000/mm³ (5,000 to 10,000/mm³): An elevated WBC may indicate infection or inflammation but does not directly influence digoxin toxicity. This finding requires assessment but is not a risk factor for digoxin-related complications.
C. Fasting glucose 150 mg/dL (74 to 106 mg/dL): Elevated glucose reflects hyperglycemia but does not affect digoxin levels or toxicity risk. It should be managed separately according to the client’s metabolic needs.
D. Triglycerides 140 mg/dL (35 to 135 mg/dL): Mildly elevated triglycerides are a cardiovascular risk factor but do not directly increase the likelihood of digoxin toxicity. Lipid management is a separate consideration.
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