A patient arrives at the emergency department with a stab wound to the chest.
The healthcare provider places two chest tubes to drain air and blood from the patient’s thoracic cavity.
Where should the nurse place the system?
Attached to the foot of the bed.
Below the level of the patient’s chest.
Along the side of the patient’s knee.
At the level of the patient’s clavicle.
The Correct Answer is B
Choice A rationale
Attaching the chest tube system to the foot of the bed is not recommended. This position could potentially cause the system to tip over or become disconnected, which could lead to complications such as pneumothorax or hemothorax.
Choice B rationale
The chest tube system should be placed below the level of the patient’s chest. This allows for gravity-assisted drainage of air and fluid from the thoracic cavity, which is crucial for the patient’s recovery. The system works on a water seal that prevents air or fluid from entering the pleural space. Placing the system below the chest level ensures that the water seal is maintained, preventing backflow of fluid or air into the pleural space.
Choice C rationale
Placing the system along the side of the patient’s knee is not appropriate. This position does not facilitate effective drainage of air and fluid from the thoracic cavity. It could also lead to discomfort and potential dislodgement of the system.
Choice D rationale
Placing the system at the level of the patient’s clavicle is not recommended. This position is too high and could disrupt the water seal, leading to ineffective drainage and potential complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A gastric residual volume of 10ml is not considered high. The client is receiving 60ml/hr of feeding, which is within normal limits. Therefore, the nurse should continue the feeding as ordered.
Correct Answer is B
Explanation
Choice B rationale
A respiratory rate of 20 breaths per minute is within the normal range for an adult, indicating that the patient’s respiratory status is stable. This would be an important indicator of the effectiveness of nursing care in a patient admitted with a lower respiratory infection.
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