A nurse is caring for a client who has a chest tube connected to a water seal drainage system.
Which action should the nurse take to ensure proper functioning of the system?
Clamp the chest tube periodically to check for air leaks.
Keep the drainage system below the level of the client's chest.
Empty the drainage chamber when it is half full.
Add sterile water to the suction control chamber as needed.
The Correct Answer is B
Keep the drainage system below the level of the client's chest.
Rationale: Keeping the drainage system below the level of the client's chest prevents backflow of fluid into the pleural space and maintains negative pressure in the system.
Incorrect options:
A) Clamp the chest tube periodically to check for air leaks. - This is an incorrect action, as clamping the chest tube can cause a tension pneumothorax or impair lung re-expansion. The nurse should only clamp the chest tube briefly when changing the drainage system or when ordered by the provider.
C) Empty the drainage chamber when it is half full. - This is an incorrect action, as emptying the drainage chamber can disrupt the water seal and allow air to enter the pleural space. The nurse should only empty the drainage chamber when it is full or when changing the system.
D) Add sterile water to the suction control chamber as needed. - This is an incorrect action, as adding sterile water to the suction control chamber can increase or decrease the amount of suction applied to the chest tube, depending on whether water is added or removed. The nurse should only add sterile water to the water seal chamber if it falls below the 2 cm mark.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
"I will quit smoking as soon as possible."
Rationale: Quitting smoking is a lifestyle modification that can lower blood pressure, as smoking causes vasoconstriction and increases cardiac workload and oxygen demand.
Incorrect options:
A) "I will limit my sodium intake to 4 grams per day." - This statement indicates a need for further teaching, as limiting sodium intake to 4 grams per day is not sufficient for someone with hypertension. The recommended daily sodium intake for individuals with hypertension is generally lower, around 1,500-2,300 milligrams (mg).
B) "I will drink no more than two cups of coffee per day." - While limiting caffeine intake is generally recommended for individuals with hypertension, this statement does not address other lifestyle modifications specifically related to blood pressure.
C) "I will exercise for at least 30 minutes three times per week." - Regular exercise is beneficial for overall health, but the frequency and duration mentioned in this statement may not be sufficient for effectively lowering blood pressure. The American Heart Association recommends at least 150 minutes of moderate-intensity aerobic exercise or 75 minutes of vigorous-intensity exercise per week for individuals with hypertension.
Correct Answer is B
Explanation
Keep the drainage system below the level of the client's chest.
Rationale: Keeping the drainage system below the level of the client's chest prevents backflow of fluid into the pleural space and maintains negative pressure in the system.
Incorrect options:
A) Clamp the chest tube periodically to check for air leaks. - This is an incorrect action, as clamping the chest tube can cause a tension pneumothorax or impair lung re-expansion. The nurse should only clamp the chest tube briefly when changing the drainage system or when ordered by the provider.
C) Empty the drainage chamber when it is half full. - This is an incorrect action, as emptying the drainage chamber can disrupt the water seal and allow air to enter the pleural space. The nurse should only empty the drainage chamber when it is full or when changing the system.
D) Add sterile water to the suction control chamber as needed. - This is an incorrect action, as adding sterile water to the suction control chamber can increase or decrease the amount of suction applied to the chest tube, depending on whether water is added or removed. The nurse should only add sterile water to the water seal chamber if it falls below the 2 cm mark.
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