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

Monitor for at least 150 mL of drainage every hour.

Clamp the tube for 30 min every 8 hr.

Pin the tubing to the client's bed sheets.

Replace the unit when the drainage chamber is full.

Answer and Explanation

The Correct Answer is A

Monitor for at least 150 mL of drainage every hour. The nurse should monitor the chest tube drainage for excessive or sudden increases in order to detect any complications, such as pneumothorax. Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications. Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided. The chest tube unit should only be replaced when there is a problem with the unit or the seals.

Choice B: Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications.

Choice C: Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided.

Choice D: The chest tube unit should only be replaced when there is a problem with the unit or the seals.

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Correct Answer is C

Explanation

The correct answer is choice C. The client's lactose intolerance places her at an increased risk for osteoporosis, as dairy products are a rich source of calcium and vitamin D, which are important for bone health. Walking daily and gardening may actually help to reduce the risk of osteoporosis, as physical activity can help to strengthen bones. Drinking red wine in moderation may provide some benefits for cardiovascular health and may not necessarily increase the risk of osteoporosis.
Reason why each of the other choices are not answers:

A is not correct because walking daily can help to improve bone health and reduce the risk of osteoporosis.

B is not correct because gardening can also provide physical activity and help to reduce the risk of osteoporosis.

D is not correct because propranolol does not typically cause increased hair growth, and requesting a dosage increase based on apical heart rate may not be necessary for all clients taking this medication.

A. Metabolic acidosis B. Respiratory acidosis C. Respiratory alkalosis D. Metabolic alkalosis

Correct Answer is B

Explanation

This ABG result indicates that the client has an excess of carbon dioxide (CO2) due to hypoventilation.

A. "Metabolic acidosis" is an incorrect answer because the pH is low and the HCO3 is within normal range.

C. "Respiratory alkalosis" is an incorrect answer because the pH is low and the PaCO2 is elevated.

D. "Metabolic alkalosis" is an incorrect answer because the HCO3 is within normal range, and the pH is low.

Explanation: The ABG result shows a low pH, elevated PaCO2, and normal HCO3, indicating respiratory acidosis. This condition can be caused by conditions that affect breathing, such as pneumonia, asthma, or chronic obstructive pulmonary disease (COPD).

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

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