The drainage in the chest tube of a client with emphysema has changed from viscous green to clear watery fluid. Which action is best for the nurse to tak?

Schedule a portable chest x-ray per PRN protocol.

Maintain the current IV antibiotic schedule.

Obtain a specimen of the drainage for culture.

"Milk" the tube to remove any clots.

Answer and Explanation

The Correct Answer is C

A.   A chest x-ray can be useful to assess for complications or changes in lung status, such as pneumothorax, pleural effusion, or changes in lung volume. However, the change in drainage color from viscous green to clear watery fluid may not immediately warrant an x-ray unless there are additional clinical concerns or symptoms suggesting a need for imaging.
B.   Continuing the IV antibiotic schedule is important if there is an ongoing infection that needs treatment. However, if the change in drainage is significant and suggests a potential change in the underlying condition or complication, it’s important to evaluate the cause of the change rather than solely relying on antibiotics.
C.   Obtaining a specimen of the drainage for culture is a valuable action if there is concern about infection or if the drainage characteristics have changed unexpectedly. Clear, watery fluid could indicate the presence of serous fluid or a change in the nature of the drainage, potentially due to infection or resolution of an infection.
D.   “Milking” or stripping the chest tube is not recommended as a routine practice because it can create negative pressure and potentially damage the pleural tissues or exacerbate issues. Additionally, the change in the drainage from viscous green to clear watery fluid does not necessarily indicate that clots are present or that tube milking would be helpful.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Diuretics can cause electrolyte imbalances and dehydration, leading to muscle weakness. The patient should report any signs of muscle weakness to the healthcare provider.
B. Weight is a good indicator of fluid loss. Monitoring daily weight and reporting excessive weight loss helps to evaluate the effectiveness of the diuretic and detect potential complications.
C. Limiting fluid intake while on a diuretic can lead to dehydration and electrolyte imbalances. Adequate fluid intake is essential.
D. Diuretics are often prescribed for long-term management of edema. The patient should not stop taking the medication without consulting the healthcare provider.

A. Initiate a referral for ophthalmic evaluation as soon as possible. B. Advise the client to maintain normal activities, but avoid contact sports until the spots resolve C. Instruct the client to rest, and report to the emergency department if eye pain develops. D. Tell the client to apply warm, moist compresses and notify the healthcare provider if there is no improvement.

Correct Answer is A

Explanation

A. The sudden onset of flashing lights and floaters can be a symptom of a detached retina, a serious eye condition that requires immediate medical attention.
B. This is incorrect. The client should not engage in any activities until the condition is evaluated by a healthcare professional.
C. While rest might seem appropriate, the client should seek immediate medical attention due to the potential seriousness of the symptoms.
D. Warm compresses are not indicated for this condition, and the client should seek immediate medical attention.

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The drainage in the chest tube of a client with emphysema has changed from viscous green to clear watery fluid. Which action is best for the nurse to tak?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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