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.

Answer and Explanation

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Stripping or milking the chest tube is an outdated practice.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.

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Correct Answer is C

Explanation

A. Right Circumstances:
This involves ensuring that the tasks being delegated are appropriate for the circumstances and consistent with the plan of care. The nurse should consider factors such as the client's condition, the complexity of the task, and the stability of the client's health status.

B. Right Communication:
Effective communication is crucial in delegation. This includes clear and concise instructions, expectations, and a feedback loop. The nurse should ensure that communication is understood and acknowledged by both parties involved in the delegation.

C. Right Supervision:
Right Supervision involves providing guidance, direction, and feedback to those to whom tasks have been delegated. The nurse is responsible for overseeing and ensuring that the tasks are performed appropriately, meeting the required standards of care. This includes ongoing monitoring and assessment of delegated tasks.

D. Right Person:
The right person involves selecting the appropriate individual for the task based on their competence, knowledge, and skills. The nurse must assess the competency of the person being delegated to and ensure that they have the necessary qualifications to perform the assigned task

A. Place the client in a private room with a special ventilation system. B. Modify the protocol for donning and removing personal protective equipment before entering or leaving the client’s room. C. Have staff and visitors wear gowns, masks, and gloves while in the client’s room. D. Assign the client to a room with other clients who require droplet precautions.

Correct Answer is A

Explanation

A. Place the client in a private room with a special ventilation system.
The primary method to prevent the transmission of tuberculosis is to place the client in a negative pressure room with adequate ventilation. This helps to reduce the risk of airborne transmission of the Mycobacterium tuberculosis bacteria.

B. Modify the protocol for donning and removing personal protective equipment before entering or leaving the client’s room:
Standard precautions should be followed, but the primary emphasis is on airborne precautions due to the potential for airborne transmission of TB. Modifications to donning and removing PPE are not the main focus.

C. Have staff and visitors wear gowns, masks, and gloves while in the client’s room:
Airborne precautions are more specific for suspected active tuberculosis. While gowns, masks, and gloves may be used for other infectious diseases, the key precaution for TB is a private room with negative pressure ventilation.

D. Assign the client to a room with other clients who require droplet precautions:
Tuberculosis is primarily transmitted through airborne particles, not droplets. Placing the client in a room with droplet precautions is not sufficient to prevent the spread of tuberculosis.

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A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?

Nursing Test Bank

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