The nurse is caring for a client who has a pneumothorax and a water-seal chest tube drainage system to suction. Which of the following actions should the nurse take?

Add tap water as needed to the suction control chamber.

Maintain the drainage container below the level of the client's chest.

Empty the collection container every shift.

Clamp the chest tubes if it becomes disconnected

Answer and Explanation

The Correct Answer is B

A. Add tap water as needed to the suction control chamber.

This is not the correct action. The suction control chamber of a water-seal chest tube drainage system is typically filled with sterile water to the prescribed level by the healthcare provider during the initial setup. Adding tap water to the suction control chamber can disrupt the balance of the system and affect the prescribed suction level. The nurse should not add tap water without specific instructions from the healthcare provider.

B. Maintain the drainage container below the level of the client's chest.

This is the correct action. In a water-seal chest tube drainage system, it's important to keep the drainage container below the level of the client's chest. This positioning allows gravity to assist in the drainage of air or fluid from the pleural space into the drainage container. It also helps prevent backflow of fluid or air into the chest cavity, ensuring the effectiveness of the drainage system.

C. Empty the collection container every shift.

While it may be necessary to empty the collection container if it becomes full, emptying it every shift is not a set rule. The frequency of emptying the collection container should be based on the volume of drainage and the facility's policy. The nurse should monitor the collection container regularly and empty it when it reaches the appropriate level, typically around half full or as indicated by facility protocol.

D. Clamp the chest tubes if it becomes disconnected.

Clamping the chest tubes if they become disconnected is not recommended. It can lead to tension pneumothorax, a life-threatening condition where air accumulates in the pleural space and compresses the lung. If a chest tube becomes disconnected, the nurse should immediately assess the situation, secure the chest tube connections, and notify the healthcare provider for further management.

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

A. Place tissue soiled with respiratory secretions in a paper bag for later disposal:

This instruction is not accurate or recommended for managing tissue soiled with respiratory secretions, particularly in the context of tuberculosis (TB) infection. TB is transmitted through the air via respiratory droplets, so proper disposal of contaminated materials is crucial to prevent the spread of the infection. Instead of placing tissue in a paper bag, it should be disposed of in a sealed plastic bag to minimize the risk of transmission. Additionally, individuals with TB should be instructed on proper respiratory hygiene practices, such as covering their mouth and nose with a tissue or their elbow when coughing or sneezing, to prevent the spread of infectious droplets.

B. Provide samples for sputum cultures every 6 weeks:

Sputum cultures are an essential component of monitoring and managing tuberculosis (TB) treatment. However, obtaining samples every 6 weeks is not frequent enough, especially during the initial phase of treatment. In the early stages of TB treatment, sputum cultures are typically obtained more frequently, often weekly or biweekly, to monitor the response to treatment, assess for drug resistance, and ensure treatment effectiveness. As treatment progresses and the patient's condition stabilizes, the frequency of sputum cultures may be adjusted based on clinical judgment and guidelines.

C. Consume alcohol in moderation while taking antituberculosis medications:

Alcohol consumption is generally discouraged while taking antituberculosis medications. Some antituberculosis drugs, such as isoniazid and rifampin, can interact with alcohol and cause adverse effects, such as liver toxicity or drug metabolism issues. Therefore, individuals undergoing treatment for tuberculosis should be advised to abstain from alcohol consumption or limit it to a minimum to avoid potential complications. Providing instructions on alcohol consumption is an important aspect of tuberculosis management and medication adherence.

D. Wear a mask while out or around crowds of people:

This instruction is crucial for individuals with pulmonary tuberculosis to prevent the spread of the infection to others. Tuberculosis is transmitted through the air via respiratory droplets, particularly when an infected person coughs, sneezes, or talks. Wearing a mask while out or in crowded settings helps reduce the risk of transmitting infectious droplets to others and is an important infection control measure. It is especially important during the early stages of treatment when the individual is still infectious and shedding bacteria. Proper mask use, along with other respiratory hygiene practices, can help protect both the individual with tuberculosis and those around them from the spread of infection.

A. Fatigue B. High fever in the early morning C. Edema D. Increased appetite

Correct Answer is A

Explanation

A. Fatigue

When collecting data from a client with pulmonary tuberculosis (TB), the nurse should expect to observe fatigue as one of the common manifestations. TB is a bacterial infection caused by Mycobacterium tuberculosis, primarily affecting the lungs. Fatigue is a typical symptom experienced by individuals with TB, often resulting from the body's immune response to the infection, as well as the systemic effects of inflammation and tissue damage caused by the bacteria.

B. High fever in the early morning

While fever is a symptom of tuberculosis, it may not necessarily occur specifically in the early morning. Fever associated with TB can occur at any time of the day and may persist for weeks to months. The pattern of fever can vary among individuals and may not consistently occur in the early morning.

C. Edema

Edema, or swelling due to fluid accumulation in tissues, is not typically associated with pulmonary tuberculosis. Edema is more commonly observed in conditions such as heart failure, renal failure, or liver disease, rather than in TB.

D. Increased appetite

Increased appetite is not a typical finding in pulmonary tuberculosis. In fact, individuals with active TB infection often experience appetite loss and unintended weight loss due to factors such as decreased food intake, metabolic changes, and systemic inflammation associated with the infection.

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

The nurse is caring for a client who has a pneumothorax and a water-seal chest tube drainage system to suction. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to review discharge instructions with a client who has pulmonary tuberculosis. Which of the following information should the nurse include?

Correct Answer is D

Explanation

A nurse is collecting data from a client who has pulmonary tuberculosis. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who has COPD about purse-lipped breathing. Which of the following statements should the nurse make?

A nurse is collecting data on a client who has COPD. Which of the following findings should the nurse expect?

A nurse is reinforcing teaching with the parents of a child who is starting to use a spacer with a metered-dose inhaler (MDI) to treat asthma. Which of the following information should the nurse include in the teaching?

A patient is admitted to the hospital with SOB. The nurse notices increasing confusion and combativeness during the past hour. Which of the following actions is appropriate first?

The nurse is providing instruction about ipratropium (Atrovent) to a patient with COPD. Which is a common adverse effect that tends to resolve with therapy?

A nurse is caring for a client who has tuberculosis and is about to start taking pyrazinamide. The nurse should identify that the client needs which of the following tests while taking this medication therapy?

A nurse at a long-term care facility is reinforcing teaching with a newly hired nurse about care of clients who are receiving mechanical ventilation. Which of the following information should the nurse include?

A nurse is reinforcing teaching with a client who is having difficulty using an incentive spirometer. Which of the following instructions should the nurse include in the teaching?