A nurse is assisting with the care of a client who has a chest tube. Which of the following actions should the nurse take?

Strip the client's chest tube every 2 hours.

Loop the tubing of the chest tube on the client's bed.

Place the chest tube drainage system above the level of the client's heart.

Tape the connections on the client's chest tube.

Answer and Explanation

The Correct Answer is D

Choice A reason: Stripping the client's chest tube every 2 hours is not a recommended action, as it can cause excessive negative pressure, tissue trauma, and pain. The nurse should only strip the chest tube if there is a clot or obstruction in the tubing, and only with the provider's order.

Choice B reason: Looping the tubing of the chest tube on the client's bed is a correct action, as it prevents kinking, tension, or pulling on the chest tube. The nurse should also secure the tubing to the bed sheet with a safety pin.

Choice C reason: Placing the chest tube drainage system above the level of the client's heart is not a correct action, as it can cause the fluid to flow back into the chest cavity and impair lung expansion. The nurse should place the chest tube drainage system below the level of the client's chest.

Choice D reason: Taping the connections on the client's chest tube is a correct action, as it prevents air leaks, disconnections, or accidental removal of the chest tube. The nurse should also check the connections regularly for tightness and patency.

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Correct Answer is A

Explanation

Choice A reason: Caffeinated beverages can cause diarrhea by stimulating the intestinal motility and increasing the fluid loss. They can also irritate the lining of the stomach and intestines.

Choice B reason: Low-fiber cereal is not likely to cause diarrhea. Fiber helps to bulk up the stool and regulate the bowel movements. Low-fiber foods are often recommended for clients with diarrhea to reduce intestinal activity.

Choice C reason: White rice is not likely to cause diarrhea. It is a bland and starchy food that can help to bind the stool and reduce fluid loss. White rice is often part of the BRAT diet (bananas, rice, applesauce, toast) that is suggested for clients with diarrhea.

Choice D reason: Ripe bananas are not likely to cause diarrhea. They are rich in potassium, which can help to replenish the electrolytes lost due to diarrhea. They also contain pectin, a soluble fiber that can help to firm up the stool.

A. Dry skin B. Diarrhea C. Abdominal pain D. Hyperventilation

Correct Answer is D

Explanation

Choice A reason: Dry skin is not a sign of respiratory alkalosis. Respiratory alkalosis is a condition where the blood pH is too high due to excessive loss of carbon dioxide through rapid breathing. Dry skin can be caused by dehydration, cold weather, or skin conditions.

Choice B reason: Diarrhea is not a sign of respiratory alkalosis. Diarrhea is a condition where the stool is loose and watery due to increased intestinal motility or infection. Diarrhea can cause metabolic acidosis, which is a condition where the blood pH is too low due to excessive loss of bicarbonate.

Choice C reason: Abdominal pain is not a sign of respiratory alkalosis. Abdominal pain is a symptom that can have many causes, such as gastritis, appendicitis, or irritable bowel syndrome. Abdominal pain can also cause hyperventilation due to anxiety or discomfort, but it is not a direct result of respiratory alkalosis.

Choice D reason: Hyperventilation is a sign of respiratory alkalosis. Hyperventilation is a condition where the breathing rate is faster than normal, causing excess carbon dioxide to be expelled from the lungs. This lowers the partial pressure of carbon dioxide in the blood, which increases the blood pH and causes alkalosis. Hyperventilation can be caused by anxiety, fever, pain, or lung diseases.

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A nurse is assisting with the care of a client who has a chest tube. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about foods and beverages that can cause diarrhea. Which of the following should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is assessing a client who has respiratory alkalosis. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

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