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
Choice A rationale
The femoral pulse is located in the groin area and is often used during procedures or when other pulse sites are not available. It does not directly assess circulation to the brain.
Choice B rationale
The radial pulse, located on the thumb side of the wrist, is commonly used to measure heart rate but does not directly assess circulation to the brain.
Choice C rationale
The carotid pulse is located on either side of the neck below the jawline. It is one of the major arteries that supply blood to the brain. In an emergency, this pulse site is used to assess circulation to the brain.
Choice D rationale
The popliteal pulse is located behind the knee and is used to assess circulation to the lower leg. It does not directly assess circulation to the brain.
Correct Answer is A
Explanation
Choice A rationale
Severe upper abdominal pain can be a sign of gastrointestinal perforation in a patient with peptic ulcer disease. When an ulcer erodes through the wall of the stomach or duodenum, it can cause a perforation, or hole. This is a serious complication that can cause severe pain.
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