A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?
Loop the tubing of the chest tube on the client’s bed.
Strip the client’s chest tube every 2 hrs.
Place the chest tube drainage system below the level of the client’s heart.
Tape the connections on the client’s chest tube.
The Correct Answer is C
A. Loop the tubing of the chest tube on the client’s bed:
Looping the tubing may create dependent loops that can trap drainage and prevent effective functioning of the chest tube. It can impede the drainage of air or fluid from the pleural space.
B. Strip the client’s chest tube every 2 hrs:
Stripping or milking the chest tube is an outdated practice. It can cause trauma to the tissue surrounding the chest tube and increase the risk of complications, including damage to the lung tissue or tubing.
C. Place the chest tube drainage system below the level of the client’s heart:
This is the correct action. Placing the chest tube drainage system below the level of the client's chest allows gravity to assist with drainage and prevents backflow or accumulation of fluids within the chest tube.
D. Tape the connections on the client’s chest tube:
Taping the connections on the chest tube is not recommended. It is important to keep connections secure, but taping can make it difficult to quickly identify and address any issues with the chest tube system during monitoring and assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Glucagon:
Glucagon is not used as an antidote for heparin overdose. It is typically used to treat severe hypoglycemia.
B. Vitamin K:
Vitamin K is the antidote for warfarin, another anticoagulant, but it is not effective for reversing the effects of heparin.
C. Protamine
Protamine is the specific antidote for heparin. It acts by binding to heparin, neutralizing its anticoagulant effects. It is important to note that the administration of protamine should be done carefully, and the dosage must be based on the amount of heparin the patient has received.
D. Calcium:
Calcium is not an antidote for heparin. It is more relevant in cases of calcium channel blocker toxicity or hypocalcemia.
Correct Answer is ["100"]
Explanation
Clindamycin is an antibiotic that can treat infections caused by staphylococci bacteria. It can be given by intermittent IV bolus, which means injecting the drug into a vein over a short period of time. To calculate the infusion rate for clindamycin, we need to use the formula:
Infusion rate (ml/hr) = Volume (ml) / Time (hr)
In this case, the volume is 50 ml and the time is 0.5 hr (30 min). Plugging these values into the formula, we get:
Infusion rate (ml/hr) = 50 ml / 0.5 hr
Infusion rate (ml/hr) = 100 ml/hr
Therefore, the nurse should set the IV pump to deliver 100 ml/hr of clindamycin.
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