A client has a chest tube connected to a closed water-seal drainage system with suction. Which equipment should the nurse always have available at the client's bedside?

Suture removal kit.

Suction catheter.

Sterile gauze dressing.

Sterile piston syringe.

Answer and Explanation

The Correct Answer is C

A. Suture removal kit. A suture removal kit is used when the chest tube is ready for removal, but it is not necessary to keep at the bedside during routine chest tube management. The priority is ensuring emergency supplies are available if the tube becomes dislodged.
B. Suction catheter. A suction catheter is used to remove secretions from the airway but is not essential for managing a chest tube. Chest drainage systems function independently to remove air or fluid, and routine suctioning is not required for chest tube management.
C. Sterile gauze dressing. If the chest tube accidentally dislodges, an occlusive dressing (such as sterile gauze with petroleum jelly) should be applied immediately to prevent air from re-entering the pleural space, which could lead to a tension pneumothorax. Keeping sterile gauze at the bedside ensures rapid intervention in case of accidental chest tube removal.
D. Sterile piston syringe. A sterile piston syringe is used for irrigating wounds or suctioning secretions, but it is not necessary for chest tube management. The closed drainage system should never be manually flushed unless specifically ordered by a healthcare provider.

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Correct Answer is C

Explanation

A. Oxygenate before suctioning. Pre-oxygenation before suctioning is essential to prevent hypoxia and bradycardia, but it does not directly ensure that the ETT remains in the correct position. This is a general airway management guideline rather than a specific intervention to maintain ETT placement.
B. Auscultate bilateral breath sounds. Auscultation is important for ongoing assessment of lung sounds and oxygenation but does not physically prevent tube displacement. While listening for equal breath sounds helps detect tube migration or mainstem bronchus intubation, it does not secure the ETT in place.
C. Firmly secure the ETT in place. After proper ETT placement is confirmed with a chest x-ray, securing the tube with adhesive tape or a commercial ETT holder prevents displacement. Unintentional extubation or tube migration can lead to hypoxia, respiratory distress, or esophageal intubation, making proper tube fixation a priority intervention.
D. Suction the ETT every 2 hours. Routine suctioning is not recommended unless there are indications such as visible secretions, high airway pressures, or decreased oxygenation. Frequent, unnecessary suctioning can cause mucosal trauma, hypoxia, and bradycardia and does not help maintain ETT placement.

A. Allow the family to touch and talk to the client. B. Reassess the client's vascular access. C. Assess neurological vital signs every 15 minutes. D. Administer ophthalmic ointment. E. Apply soft bilateral wrist restraints for transport.

Correct Answer is ["A","B","C","D"]

Explanation

A. Allow the family to touch and talk to the client. Family presence can provide emotional support for both the client and loved ones. Even though the client is sedated and has a low GCS, familiar voices and touch may reduce stress and anxiety. Allowing family interaction fosters comfort and connection during a critical time.
B. Reassess the client's vascular access. Maintaining secure and functional vascular access is essential for administering fluids, medications, and emergency interventions. Before transport, the nurse should confirm IV patency, ensure secure connections, and assess for signs of infiltration or malfunction. Trauma patients may require additional or larger bore IV access for fluid resuscitation or transfusion.
C. Assess neurological vital signs every 15 minutes. Frequent neurological assessments are crucial in head trauma patients with a low GCS to monitor for signs of worsening intracranial pressure, cerebral edema, or herniation. Changes in pupil response, motor function, or vital signs may indicate neurological deterioration requiring urgent intervention. Monitoring trends over time is necessary for early detection of complications.
D. Administer ophthalmic ointment. Clients with a low GCS often have impaired blinking, placing them at risk for corneal abrasions and dryness. Applying ophthalmic lubricant or artificial tears protects the cornea from injury and promotes eye health. Preventing exposure keratitis is essential in unconscious or sedated clients to avoid long-term ocular damage.
E. Apply soft bilateral wrist restraints for transport. Restraints are unnecessary because the client is sedated, intubated, and has a GCS of 6, meaning they cannot attempt self-extubation or interfere with care. Restraints should only be used if the client demonstrates a risk of harm. Standard transport protocols prioritize sedation and safety measures over restraints unless specifically required.

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A client has a chest tube connected to a closed water-seal drainage system with suction. Which equipment should the nurse always have available at the client's bedside?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After intubating a client, correct placement of the endotracheal tube (ETT) is confirmed with a chest x-ray. Which intervention should the nurse implement to ensure that the ETT placement is maintained?

Correct Answer is C

Explanation

An adult with head and facial injuries from a motor vehicle collision is fully immobilized and has a Glasgow coma score of 6. The client is intubated, sedated, and is being prepared for transfer to a regional trauma center. Which intervention(s) should the nurse implement? Select all that apply.

Correct Answer is ["A","B","C","D"]

Explanation

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