A nurse is assisting with the care of a client who has a newly inserted chest tube. Which of the following actions should the nurse take?
Loop the client's tubes carefully to prevent kinking.
Clamp the tube when the client is ambulating.
Place the client flat to avoid leaks in the tubing.
Keep the collection device below the client's chest level.
The Correct Answer is D
A. Loop the client's tubes carefully to prevent kinking: Tubes should not be unnecessarily looped, as this may cause obstruction or tension.
B. Clamp the tube when the client is ambulating: Clamping increases the risk of tension pneumothorax and should be avoided unless prescribed for specific procedures.
C. Place the client flat to avoid leaks in the tubing: This position may compromise lung expansion; semi-Fowler’s or Fowler’s position is preferred.
D. Keep the collection device below the client’s chest level: This position uses gravity to prevent backflow of fluid or air into the pleural space.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Assist the client to Fowler's position: This position helps maximize lung expansion, making it easier for the client to breathe.
B. Promote removal of pulmonary secretions: Important but secondary to addressing immediate respiratory distress.
C. Increase the oxygen flow: This should only be done per provider order to avoid complications such as oxygen toxicity.
D. Obtain a specimen for arterial blood gases: This is a diagnostic step but not an immediate intervention for difficulty breathing.
Correct Answer is D
Explanation
A) Secure the tracheostomy ties so that fingers cannot fit between the ties and the neck. The ties should be secure but loose enough to fit one finger between the ties and the neck to prevent skin breakdown and maintain comfort.
B) Suction for 20 seconds. Suctioning for 20 seconds is too long and may cause hypoxia. Suction should not exceed 5 to 10 seconds.
C) Clean secretions from the tube using hydrogen peroxide. Hydrogen peroxide can irritate the delicate tissues and is not recommended. Saline or prescribed cleaning agents are preferred.
D) Set the vacuum pressure at 120 mmHg for suctioning. For a toddler, suction pressure should typically be between 80 and 120 mmHg to prevent mucosal damage.
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