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 C
Explanation
A. The client is grasping his abdomen: Grasping the abdomen may indicate pain or cramping, not necessarily airway obstruction.
B. The client is coughing: Effective coughing suggests that the airway is partially open and the client is moving air, meaning abdominal thrusts are not required.
C. The client cannot speak: Inability to speak or cough is a sign of complete airway obstruction, indicating the need for abdominal thrusts.
D. The client is hyperventilating: Rapid breathing is not a typical sign of choking and does not warrant abdominal thrusts.
Correct Answer is A
Explanation
A. Two deep breaths, then inhale deeply again and force out the air quickly: This technique helps clear mucus by mobilizing it toward the larger airways for expulsion.
B. One deep breath and quickly exhale: This method is less effective in mobilizing secretions compared to multiple preparatory breaths.
C. One breath, hold it for 3 seconds, then forcefully exhale three times with mouth open: Holding the breath promotes mucus loosening, and repeated exhalations help clear secretions. While this technique can be correct in some protocols, it is less common for "forceful" cough instructions and may not be the preferred method.
D. Two breaths and force the air out quickly: Lacks the preparatory deep breath necessary for effective secretion clearance.
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