A nurse is caring for a client who has a chest tube inserted for a pneumothorax. Which of the following actions should the nurse take?
Empty the collection chamber on the client’s chest tube every 4 hr.
Strip the client’s chest tube every 2 hr.
Pin the chest tube to the client’s gown.
Tape the connections on the client’s chest tube.
The Correct Answer is D
Choice A reason: Emptying the collection chamber every 4 hours is unnecessary and can increase the risk of introducing infection. The chamber should be emptied as needed based on the volume of drainage.
Choice B reason: Stripping the chest tube, which involves squeezing and releasing sections of the tube to move clots, is not recommended as it can create high negative pressure and cause damage to the lung tissue.
Choice C reason: Pinning the chest tube to the client’s gown can lead to accidental dislodgement. The chest tube should be secured appropriately without tension.
Choice D reason: The correct answer is d because taping the connections on the client’s chest tube ensures that the system remains airtight and prevents air leaks, which is essential for effective functioning of the chest tube and prevention of pneumothorax recurrence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: A blood pressure of 134/82 mm Hg is within the normal range and typically does not require immediate intervention. It is important to monitor blood pressure trends, but this value alone is not concerning.
Choice B reason: The correct answer is b because headache and restlessness can be signs of dialysis-related complications such as disequilibrium syndrome or fluid and electrolyte imbalances. These symptoms should be reported to the provider for further evaluation and management.
Choice C reason: A palpable thrill at the AV fistula access site indicates that the fistula is functioning properly. This is an expected finding and does not require intervention.
Choice D reason: A heart rate of 65 bpm is within the normal range for most adults and does not typically require immediate intervention unless associated with other symptoms or abnormalities.
Correct Answer is B
Explanation
Choice A reason: Brudzinski's sign is an indicator of meningitis, where flexion of the neck causes involuntary flexion of the hips and knees. This sign is not related to hypocalcemia and is more specific to central nervous system infections.
Choice B reason: Chvostek's sign is a clinical sign of hypocalcemia. It is elicited by tapping on the facial nerve in front of the ear, which causes twitching of the facial muscles. This sign indicates neuromuscular irritability due to low calcium levels and is a key indicator for diagnosing hypocalcemia.
Choice C reason: Cullen's sign is a superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus. It is associated with acute pancreatitis and intra-abdominal bleeding, not hypocalcemia. Therefore, it is not an appropriate sign to monitor for in clients with hypocalcemia.
Choice D reason: Kernig's sign is another indicator of meningitis. It involves pain and resistance to knee extension when the hip is flexed. Like Brudzinski's sign, it is specific to meningitis and is not related to hypocalcemia. Monitoring for this sign would not be relevant for a client with low calcium levels.
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