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A nurse is assisting with the plan of care for a client who has a chest tube connected to a closed chest drainage system. Which of the following interventions should the nurse include in the plan of care?

Empty the collection chamber every 12 hr.

Keep the collection device below the level of the client's chest.

Avoid positioning the client on the affected side

Strip the chest tube every 4 hr.

Answer and Explanation

The Correct Answer is B

A. Empty the collection chamber every 12 hr:

The collection chamber should not be emptied; it is changed when full to maintain system integrity and accuracy.

B. Keep the collection device below the level of the client's chest:

This ensures gravity drainage and prevents backflow of fluid into the pleural space.

C. Avoid positioning the client on the affected side:

Positioning on the affected side is not contraindicated and may even promote lung expansion and comfort.

D. Strip the chest tube every 4 hr:

Stripping the chest tube is not routinely recommended as it may cause excessive negative pressure and damage lung tissue.

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Correct Answer is A

Explanation

A. Asking the client to rate the pain and assess the site for decreased swelling:

This combines both subjective (pain rating) and objective (swelling) indicators of whether the treatment is working.

B. Having the client perform range-of-motion exercises of the arm:

This does not directly assess the effectiveness of cold therapy and may aggravate a fresh injury.

C. Inspecting the site for increased swelling:

This may indicate ineffective treatment, not effectiveness.

D. Monitoring the client’s pulse rate:

Pulse rate is not a reliable measure for evaluating local pain or swelling.

A. Check the client for bladder distention B. Lower the head of the client's bed. C. Remove the client's peripheral IV D. Check the client's gag reflex.

Correct Answer is D

Explanation

A. Check the client for bladder distention:

This is unrelated to the request for oral intake. Bladder checks are more relevant to urinary retention, not swallowing safety.

B. Lower the head of the client's bed:

This increases risk of aspiration. The head of the bed should be elevated when consuming anything orally.

C. Remove the client's peripheral IV:

This is not appropriate. The IV may still be needed for medications, fluids, or emergencies.

D. Check the client's gag reflex:

This assesses swallowing safety to prevent aspiration, especially important post-anesthesia before giving oral intake.

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A nurse is assisting with the plan of care for a client who has a chest tube connected to a closed chest drainage system. Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

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