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.

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Correct Answer is D

Explanation

A. Position the client on the nonoperative side.

Positioning the client on the nonoperative side after a pneumonectomy may not be the best choice. The positioning of the client post-pneumonectomy should be based on factors such as the individual's comfort, respiratory status, and any specific instructions from the healthcare provider. Placing the client on the nonoperative side may inadvertently put pressure on the surgical site, leading to discomfort or potential complications.

B. Monitor respiratory status every 8 hr.

Monitoring respiratory status every 8 hours is not sufficient for a client post-pneumonectomy. After such a major surgical procedure, respiratory status should be closely monitored and assessed more frequently, especially in the immediate postoperative period. This frequency allows for the early detection of any signs of respiratory distress, such as decreased oxygen saturation, dyspnea, or abnormal breath sounds, as well as complications like pneumothorax or atelectasis.

C. Elevate the head of the bed to a 15° angle.

Elevating the head of the bed to a 15° angle is a general recommendation for clients postoperative to promote respiratory function and reduce the risk of aspiration. However, after a pneumonectomy, the positioning of the client may vary based on their individual condition and surgical approach. It's important to follow the healthcare provider's specific instructions regarding positioning for optimal recovery. The angle of elevation may need to be adjusted based on the client's comfort and respiratory status.

D. Encourage the client to splint the incision when coughing.

After a pneumonectomy, it's crucial to encourage the client to splint the incision when coughing. Splinting the incision with a pillow or hands helps to reduce pain and prevent strain on the surgical site, promoting healing and minimizing the risk of complications such as wound dehiscence (opening of the surgical incision).

A. Instruct the client to use a pursed-lip breathing technique. B. Evaluate the client's respiratory status. C. Increase the oxygen flow to 3L/min. D. Have the client cough and expectorate secretions.

Correct Answer is B

Explanation

A. Instruct the client to use a pursed-lip breathing technique.

Pursed-lip breathing is a technique commonly used to help relieve dyspnea, particularly in individuals with COPD. This technique involves breathing in through the nose and exhaling slowly through pursed lips, which helps to prolong exhalation, reduce airway collapse, and improve oxygen exchange. While pursed-lip breathing can be beneficial, it should not be the priority action when the client reports difficulty breathing. Before initiating any breathing techniques, the nurse should first assess the client's respiratory status to determine the severity of the breathing difficulty and whether additional interventions are necessary.

B. Evaluate the client's respiratory status.

This is the correct priority action in this scenario. When a client with COPD reports difficulty breathing, the nurse's first step should be to thoroughly assess the client's respiratory status. This assessment involves evaluating respiratory rate, depth, effort, oxygen saturation levels, auscultating lung sounds, and assessing for signs of respiratory distress. By conducting a comprehensive assessment, the nurse can determine the severity of the client's symptoms, identify any potential exacerbating factors or complications, and make informed decisions regarding appropriate interventions.

C. Increase the oxygen flow to 3 L/min.

While increasing the oxygen flow may be a consideration if the client's oxygen saturation is low, it should not be the immediate priority without first assessing the client's respiratory status. Increasing oxygen flow without proper assessment could potentially worsen hypercapnia in some COPD patients and may not address the underlying cause of the client's difficulty breathing. Therefore, this action should be based on assessment findings rather than being the initial response.

D. Have the client cough and expectorate secretions.

Coughing and expectorating secretions can be helpful in clearing the airways and improving breathing in individuals with COPD, especially if secretions are contributing to the difficulty breathing. However, similar to the pursed-lip breathing technique, this action should not be the priority without first assessing the client's respiratory status. The nurse should determine whether secretions are indeed present and causing the difficulty breathing before instructing the client to cough and expectorate. Therefore, this option should follow a thorough respiratory assessment.

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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

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Explanation

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