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 A
Explanation
Choice A reason: The correct answer is a because refusing to look at the dressing or surgical incision can indicate that the client is having difficulty accepting the loss of her breast. This behavior may suggest that the client is struggling with body image issues, grief, or denial about the changes to her body.
Choice B reason: Requesting pain medication every 3 hours is a common postoperative behavior to manage pain and does not necessarily indicate difficulty adjusting to the loss of a breast. Pain management is a normal part of recovery.
Choice C reason: Asking questions about the information on the postoperative care pamphlet demonstrates an interest in understanding and managing her care. This behavior indicates that the client is engaged in her recovery process, rather than struggling to adjust.
Choice D reason: Performing arm exercises once or twice each day shows that the client is following postoperative care instructions and is actively participating in her rehabilitation. This behavior does not suggest difficulty adjusting to the loss of her breast.
Correct Answer is C
Explanation
Choice A reason: Applying lotion to the skin around the edges of the splint may increase moisture and friction, which can contribute to skin breakdown. It is better to use protective dressings to reduce friction.
Choice B reason: Turning the client every 4 hours is not frequent enough. Clients in skeletal traction should be repositioned frequently, typically every 2 hours, to prevent pressure ulcers and maintain skin integrity.
Choice C reason: The correct answer is c because padding the top of the splint with protective dressings helps reduce friction and pressure on the skin, preventing skin breakdown and ensuring the client's comfort.
Choice D reason: Applying a footplate to the bed is not directly related to preventing skin breakdown. The primary focus should be on reducing friction and pressure around the splint.
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