A nurse is caring for a client on the medical-surgical unit.
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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. This task pertains more to secondary prevention, which aims to detect and treat HIV early through screenings and interventions.
B. This task is related to primary prevention, which aims to prevent HIV transmission through education and immunizations.
C. Tertiary prevention focuses on managing and reducing the impact of a disease or condition to prevent complications and promote quality of life. Using an electronic
messaging system to remind clients to take medications aligns with tertiary prevention by helping to manage HIV and prevent disease progression.
D. This task is more aligned with primary prevention, focusing on promoting healthy behaviors to prevent HIV transmission and disease development.
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.
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