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.

Add water to the water seal chamber as it evaporates.

Mark the drainage output on the collection chamber.

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

Strip the chest tube vigorously to dislodge blood clots.

Answer and Explanation

Correct Answer : B,C

Rationale:

A. Clamp the chest tube every 2 hr to assess the amount of drainage: Clamping a chest tube is not routine and can lead to tension pneumothorax by preventing air or fluid from escaping the pleural space. It should only be done briefly and under specific provider direction.

B. Add water to the water seal chamber as it evaporates: Water in the water seal chamber may evaporate over time and should be maintained at the prescribed level to preserve the one-way seal. This ensures proper functioning of the chest drainage system.

C. Mark the drainage output on the collection chamber: Marking the drainage level at regular intervals allows for accurate monitoring of output trends, which can help detect complications like hemorrhage or increased fluid accumulation.

D. Maintain the collection chamber above the level of the client's waist: The collection chamber should be kept below the level of the chest to promote gravity drainage. Elevating it above the waist can allow fluid or air to flow back into the pleural space.

E. Strip the chest tube vigorously to dislodge blood clots: Stripping is not recommended as it creates high negative pressure that may damage lung tissue. If clots are suspected, milking the tube gently or other interventions should be discussed with the provider.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Rationale:

A. The client advances the walker and takes a step towards it: This is the correct technique for using a walker. The client should move the walker a short distance ahead, then step into it one foot at a time, maintaining balance and stability throughout the motion.

B. The client grasps the walker by the hand grips on the upper bars: Holding the walker by its designated hand grips is safe and appropriate. This ensures proper control of the device and minimizes the risk of slipping or tipping.

C. The client lifts the walker as it is moved forward: Walkers should be lifted and placed rather than dragged to maintain balance and prevent tripping. This action demonstrates proper use and helps maintain floor contact with all legs of the walker.

D. The client takes multiple steps while holding the walker: Taking multiple steps without first advancing the walker compromises balance and increases the risk of falling. The correct method involves moving the walker first, then taking one step at a time toward it.

A. Tenting skin turgor B. Respiratory rate 30/min C. Skin warm and dry D. Heart rate 60/min

Correct Answer is B

Explanation

Rationale:

A. Tenting skin turgor: Tenting indicates dehydration or fluid volume deficit, not overload. It reflects reduced skin elasticity due to poor interstitial fluid volume.

B. Respiratory rate 30/min: Tachypnea can result from pulmonary congestion or edema due to excess fluid in the intravascular space. It is a classic sign of fluid overload as the lungs struggle with impaired gas exchange.

C. Skin warm and dry: Warm, dry skin is a normal finding and does not suggest volume overload. Fluid retention typically causes edema or moist skin in severe cases.

D. Heart rate 60/min: A heart rate within normal range does not point to fluid overload. Often, fluid overload is associated with tachycardia due to increased preload and compensatory responses.

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 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

A charge nurse is supervising a newly hired nurse who is instructing a client about how to use a walker. For which of the following actions should the charge nurse intervene?

Correct Answer is D

Explanation

A nurse is evaluating a client who received intermittent IV fluids. Which of the following findings indicates the client has a fluid overload?

Correct Answer is B

Explanation

A nurse is planning care for a client who has reduced visual sensory perception. Which of the following interventions should the nurse include in the plan of care?

A nurse in a pediatric clinic is reviewing the laboratory results of a school-age child. Which of the following findings indicates the child may have a potential bacterial infection?

A nurse is caring for a client who is to undergo a bilateral prophylactic mastectomy. The client states that her family opposes her decision. Which of the following responses should the nurse make?

A nurse is caring for a client who has an ectopic pregnancy. Which of the following findings should the nurse expect?

A nurse is assessing a client who is taking clozapine. For which of the following adverse effects should the nurse monitor and report to the provider?

A nurse is performing an abdominal assessment as part of a client's comprehensive physical examination. Which of the following is the final step the nurse should perform?

A nurse on an inpatient mental health unit is caring for a client. Exhibits Drag words from the choices below to fill each blank in the following sentence. The nurse should identify the client is experiencing dropdown and dropdown.

A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (Select all that apply.)