The nurse is caring for a client with a chest tube. Which is the following statements is appropriate regarding a chest tube?

The chest tube drainage system should be placed on the bedside table.

The chest tube drainage system should be placed on the bed near the patient.

The chest tube drainage system must be placed below the site of insertion.

The chest tube drainage system should be placed on the siderail near the patient.

Answer and Explanation

The Correct Answer is C

: Chest tube placement is done to remove air or ﬂuid from the pleural space, which is the area between the lungs and the chest wall. The chest tube drainage system is an important tool to monitor and manage the drainage from the chest tube.

It is essential that the chest tube drainage system is placed below the level of the patient's chest and the site of insertion. This is necessary to create a continuous drainage system by allowing gravity to assist in the ﬂow of air or ﬂuid out of the pleural space. If the chest tube drainage system is placed above the insertion site, the ﬂuid will not drain properly, which can cause the ﬂuid to back up into the patient's chest cavity, leading to complications such as pneumothorax or hemothorax.

Therefore, the appropriate statement regarding a chest tube is that the chest tube drainage system must be placed below the site of insertion.

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Correct Answer is C

Explanation

Dehydration can cause a decrease in blood volume, leading to a drop in blood pressure (hypotension) and an increase in heart rate (tachycardia) as the body tries to compensate. Tenting skin and dry mucous membranes are also signs of dehydration, but wet mucous membranes are not. Crackles in the lungs, edema, and confusion can occur with ﬂuid overload, but not with dehydration.

A. Put a hat in the toilet to collect proper output. B. Assess your patient’s lower extremities and lungs for ﬂuid retention. C. Educate her on the importance of writing down all ﬂuids she is drinking. D. Document the numbers anyway, there is a probable error with the intake number.

Correct Answer is B

Explanation

. Assess your patient’s lower extremities and lungs for ﬂuid retention.

If a patient’s intake is 2500ml and her output is 1200ml from a catheter bag, and you are concerned that she may not be excreting enough urine for the amount of water she is taking in, the most appropriate next step would be to assess her lower extremities and lungs for ﬂuid retention. This can help determine if the patient is retaining water and if further intervention is necessary.

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The nurse is caring for a client with a chest tube. Which is the following statements is appropriate regarding a chest tube?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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