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Stripping or milking the chest tube is an outdated practice.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

Explanation

A. PEEP decreases the peak respiratory pressures:
PEEP may increase peak respiratory pressures, especially during inspiration, but its primary purpose is to prevent alveolar collapse and improve oxygenation.

B. “PEEP increases the number of breaths the patient takes on his own.”:
PEEP does not increase the number of breaths the patient takes. It primarily affects the quality of ventilation by preventing alveolar collapse.

C. “PEEP augments the patient’s overall tidal volumes.”:
PEEP does not necessarily increase overall tidal volumes. It focuses on maintaining positive pressure at the end of expiration to prevent alveolar collapse.

D. “PEEP improves oxygenation by keeping alveoli open after exhalation.”
Positive end-expiratory pressure (PEEP) is used in mechanical ventilation to maintain positive pressure in the airways and alveoli at the end of the respiratory cycle (expiration). This helps prevent alveolar collapse and improves oxygenation by keeping the alveoli open, particularly in patients with conditions like acute respiratory distress syndrome (ARDS). PEEP is commonly used to increase functional residual capacity (FRC) and improve oxygenation.

A. Fluctuation of the fluid level within the water seal chamber B. Equal amounts of fluid drainage in each collection chamber C. Continuous bubbling within the water seal chamber D. Absence of fluid in the drainage tubing

Correct Answer is A

Explanation

A. Fluctuation of the fluid level within the water seal chamber
Fluctuation of the fluid level within the water seal chamber indicates that the chest tube is functioning properly. This fluctuation is a normal finding and reflects the movement of air in and out of the pleural space during the respiratory cycle. As the patient inhales, the fluid level drops, and as they exhale, it rises.

B. Equal amounts of fluid drainage in each collection chamber:
Equal amounts of drainage may suggest a problem with the drainage system or that the chest tube is not effectively draining air or fluid from the pleural space.

C. Continuous bubbling within the water seal chamber:
Continuous bubbling in the water seal chamber may indicate an air leak, which is not a normal finding. It should be investigated further.

D. Absence of fluid in the drainage tubing:
The absence of fluid in the drainage tubing may suggest that the chest tube is not effectively draining fluid from the pleural space or that there is a blockage in the system. It requires assessment and intervention.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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