A nurse is assisting with the care of a client who has a chest tube in place following a thoracotomy. Which of the following actions should the nurse take?
Empty the drainage container every 4 hr.
Change the client's insertion-site dressing each shift.
Clamp the chest tube when the client is ambulating.
Place the drainage unit below the client's chest level.
The Correct Answer is D
Choice A reason: This is an incorrect action, because emptying the drainage container every 4 hr is not necessary and can interfere with the accurate measurement of the drainage volume. The drainage container should be emptied only when it is full or at the end of the shift.
Choice B reason: This is an incorrect action, because changing the client's insertion-site dressing each shift can increase the risk of infection and dislodgment of the chest tube. The insertion-site dressing should be changed only when it is soiled or loose.
Choice C reason: This is an incorrect action, because clamping the chest tube when the client is ambulating can cause a tension pneumothorax, which is a life-threatening complication of chest tube insertion. The chest tube should be clamped only when ordered by the provider or when changing the drainage system.
Choice D reason: This is the correct action, because placing the drainage unit below the client's chest level can facilitate the drainage of air and fluid from the pleural space by gravity. The drainage unit should be kept below the client's chest level at all times.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is a correct statement, because using a soft toothbrush or foam swab for oral care can help prevent trauma and irritation to the mucous membranes of the mouth, which are inflamed and ulcerated due to stomatitis. The client should brush the teeth gently and avoid using dental floss.
Choice B reason: This is an incorrect statement, because using an alcohol-based mouthwash can cause burning, drying, and further damage to the mucous membranes of the mouth, which are already compromised by stomatitis. The client should avoid using any mouthwash that contains alcohol, menthol, or other harsh ingredients.
Choice C reason: This is a correct statement, because using a straw when drinking liquids can help reduce the contact and friction of the fluids with the mouth sores, which can cause pain and discomfort. The client should drink plenty of fluids to prevent dehydration and maintain hydration.
Choice D reason: This is a correct statement, because rinsing the mouth frequently with a hydrogen peroxide solution can help cleanse and disinfect the mouth, and promote healing of the mouth sores. The client should dilute the hydrogen peroxide with water and rinse the mouth at least four times a day, or as prescribed by the provider.
Correct Answer is D
Explanation
Choice A reason: This is a normal finding, not an indication of breast cancer. Lumps that are mobile and tender upon palpation prior to a menstrual period are usually benign and related to hormonal changes.
Choice B reason: This is a normal finding, not an indication of breast cancer. Multiple round masses that are tender and found in both breasts are usually benign and related to fibrocystic breast changes.
Choice C reason: This is a normal finding, not an indication of breast cancer. Bilaterally darkened areolas are usually benign and related to genetic factors, pregnancy, or aging.
Choice D reason: This is an abnormal finding, and an indication of breast cancer. A nontender hard lump that is palpated in one breast is usually malignant and related to abnormal cell growth.
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