A nurse has just received report on 4 clients who all have chest tubes in place. Which client is the priority to see first?

The client with suction pressure set at -20 cmH2O.

The client with bubbling in the drainage tubing.

The client whose drainage system is standing on the floor.

The client with continuous bubbling in the drainage chamber.

Answer and Explanation

The Correct Answer is D

Choice A reason: Suction pressure at -20 cmH2O is standard for chest tubes and not an immediate concern. Continuous bubbling suggests a pneumothorax, making this incorrect, as it’s a normal setting compared to the priority of addressing a potential air leak in the system.

Choice B reason: Bubbling in the drainage tubing is normal with fluid movement, not indicating an issue. Continuous bubbling in the chamber suggests an air leak, making this incorrect, as it’s less urgent than the priority client with a potential pneumothorax requiring immediate assessment.

Choice C reason: A drainage system on the floor risks tipping but is less urgent than continuous bubbling indicating an air leak. The pneumothorax risk takes precedence, making this incorrect, as it’s a secondary issue compared to the priority client’s chest tube complication.

Choice D reason: Continuous bubbling in the drainage chamber suggests an air leak or pneumothorax, a critical complication requiring immediate assessment. This aligns with chest tube management priorities, making it the correct client for the nurse to see first to address a potential emergency.

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Correct Answer is C

Explanation

Choice A reason: Clamping the T-tube risks bile backup and infection, especially with 750 mL drainage. Notifying the surgeon addresses potential complications, making this incorrect, as it’s unsafe compared to the nurse’s priority of reporting excessive T-tube output.

Choice B reason: Irrigating the T-tube without medical orders risks dislodging it or causing infection. Notifying the surgeon is appropriate for 750 mL drainage, making this incorrect, as it’s risky compared to the nurse’s action to seek medical evaluation.

Choice C reason: Notifying the surgeon is most appropriate, as 750 mL of T-tube drainage may indicate a complication like bile leak or obstruction. This aligns with post-surgical care protocols, making it the correct intervention for the nurse to address excessive drainage.

Choice D reason: Documenting is necessary but doesn’t address the potential complication of 750 mL drainage. Notifying the surgeon is urgent, making this incorrect, as it delays the nurse’s priority of reporting a significant post-surgical T-tube output to the surgeon.

A. The student nurse flushes the gastrostomy tube with 15 mL water between medications. B. The student nurse reinserts 50 mL stomach contents after aspiration of the gastrostomy tube. C. The student nurse checks the pH of the gastric aspirate prior to flushing the gastrostomy tube. D. The student nurse reconnects the enteral feeding immediately after the medication is given.

Correct Answer is D

Explanation

Choice A reason: Flushing with 15 mL water between medications is correct to prevent clogging and ensure delivery. Immediate feeding reconnection risks phenytoin absorption, making this incorrect, as it’s a proper action unlike the error requiring the nurse’s immediate intervention.

Choice B reason: Reinserting 50 mL of aspirated stomach contents is acceptable to maintain fluid balance. Reconnecting feeding immediately affects phenytoin efficacy, making this incorrect, as it’s a correct action compared to the student’s error needing the nurse’s urgent correction.

Choice C reason: Checking gastric aspirate pH confirms tube placement, a safety step. Immediate feeding reconnection reduces phenytoin absorption, making this incorrect, as it’s a proper action unlike the student’s mistake requiring the nurse’s immediate intervention for medication administration.

Choice D reason: Reconnecting enteral feeding immediately after phenytoin reduces its absorption, as feedings should be held for 1-2 hours. This requires immediate intervention, aligning with medication administration protocols, making it the correct action for the nurse to address in the student’s care.

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A nurse has just received report on 4 clients who all have chest tubes in place. Which client is the priority to see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notes that a client’s T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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