A nurse is caring for a client on the medical-surgical unit.

Exhibits

For each potential nursing action, click to specify if the action is indicated or contraindicated for the client who has a chest tube.

Clamp chest tube when client ambulates.

Report burning pain in chest to provider.

Reinforce dressing around the tube as needed if it loosens.

Maintain water level at 2 cm.

Strip the tubing twice daily to ensure patency

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}

A.   Clamping the chest tube during ambulation can lead to increased intrathoracic pressure, which may cause tension pneumothorax or other complications. Chest tubes should remain unclamped to maintain proper drainage. However, it may be done briefly during tube changes or if there is a suspected air leak, always under specific medical orders.
B.   Burning pain in the chest could indicate complications such as infection or irritation at the insertion site. Reporting this symptom to the provider allows for timely assessment and intervention.
C.   A loose dressing around the chest tube can compromise the integrity of the system, leading to air leaks or contamination. Reinforcing the dressing helps maintain a sterile environment and prevents dislodgement of the tube.
D.   Maintaining the appropriate water seal level in the chest drainage system is essential for proper functioning. This prevents air from entering the pleural space while allowing drainage to occur effectively.
E.   Stripping or milking the chest tube is no longer a recommended practice as it can cause damage to the tissues and lead to airway obstruction or clot formation. Instead, gentle manipulation or rotation of the tubing may be done if there are signs of occlusion, but routine stripping is not recommended

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is C

Explanation

A: Percussion should be performed with a cupped hand to provide effective airway clearance, not with a flat hand.
B: Postural drainage is typically performed multiple times per day to help clear secretions from the lungs in cystic fibrosis.
C: Postural drainage is often performed before meals to minimize the risk of vomiting due to manipulation of the abdomen.
D: Bronchodilators are not typically administered after postural drainage; they are used to help open the airways before the procedure.

A. A client who is scheduled for a colonoscopy and is taking sodium phosphate. B. A client who received a Mantoux test 48 hr ago and has an induration. C. A client who is taking bumetanide and reports an increase in urination D. A client who is taking warfarin and has started to breastfeed.

Correct Answer is A

Explanation

A: A client who is scheduled for a colonoscopy and is taking sodium phosphate requires follow-up care because sodium phosphate can cause colonic mucosal damage and electrolyte imbalances that may affect the safety and accuracy of the colonoscopy. Sodium phosphate is a bowel preparation agent that empties the colon before the procedure, but it can also cause dehydration, kidney injury, and cardiac arrhythmias.
B: Induration following a Mantoux test indicates a reaction that may suggest tuberculosis exposure, but this is an expected result that requires assessment rather than immediate follow-up.
C: Bumetanide is a diuretic, and an increase in urination is an expected effect of this medication.
D: Warfarin is considered safe during lactation since it is not excreted in breastmilk to any measurable degree.

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A nurse is caring for a client on the medical-surgical unit. Exhibits For each potential nursing action, click to specify if the action is indicated or contraindicated for the client who has a chest tube.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings requires follow-up care?

Correct Answer is A

Explanation

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A nurse is caring for a client on the medical-surgical unit.

Exhibits

For each potential nursing action, click to specify if the action is indicated or contraindicated for the client who has a chest tube.