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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Directly over the umbilicus: This position is too low and would not generate effective pressure on the diaphragm.
B. Directly over the sternum: Applying pressure here risks injury to the chest cavity without effectively relieving airway obstruction.
C. Between the umbilicus and the symphysis pubis: This position is too low and ineffective for compressing the diaphragm.
D. Halfway between the xiphoid process and the umbilicus: This is the correct hand placement for the Heimlich maneuver to produce effective inward and upward pressure, dislodging the obstruction.

A. clamp the chest tube and place the patient in high Fowler's position B. immediately turn the patient to the side of the insertion site C. document findings D. check for air leaks in drainage system

Correct Answer is D

Explanation

A. Clamp the chest tube and place the patient in high Fowler’s position: Clamping the tube may cause tension pneumothorax and should be done only with a specific prescription.
B. Immediately turn the patient to the side of the insertion site: This action does not address the source of constant bubbling.
C. Document findings: Bubbling in the suction chamber can be normal, but documenting without further assessment may overlook potential system issues.
D. Check for air leaks in the drainage system: Constant bubbling may indicate an air leak, which requires immediate assessment and correction.

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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?

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Naxlex Comprehensive Predictor Exams

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