A nurse is caring for a client who has a chest tube with a closed drainage system. Which of the following actions should the nurse take?
Milk the chest tube at least three times a day
Empty the drainage collection chamber when full
Ensure intermittent bubbling is present in the water seal chamber
Clamp the chest tube when transferring the client from bed to the chair
The Correct Answer is C
A. Milk the chest tube at least three times a day: Milking is generally not recommended as it can increase intrathoracic pressure and damage lung tissue. It should only be done with a provider’s order and specific indication.
B. Empty the drainage collection chamber when full: The collection chamber is a closed system and should not be emptied. When full, the entire drainage unit should be replaced to maintain sterility.
C. Ensure intermittent bubbling is present in the water seal chamber: Intermittent bubbling in the water seal chamber is expected during expiration or coughing, indicating air leaving the pleural space. However, continuous bubbling may suggest an air leak and requires evaluation.
D. Clamp the chest tube when transferring the client from bed to the chair: Clamping the tube is contraindicated during transport, as it can cause tension pneumothorax. The system should remain unclamped and below chest level.
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Related Questions
Correct Answer is D
Explanation
A. The Emergency Medical Treatment and Active Labor Act requires that emergency care be provided regardless of the client’s behavior, as long as the client is seeking treatment for an emergency medical condition.
B. EMTALA requires that a client receive a medical screening and stabilization before being transferred, regardless of whether the condition is terminal. A terminal diagnosis does not justify transferring a client without stabilization first.
C. EMTALA prohibits discrimination based on a client’s ability to pay. A client cannot be transferred or discharged from an emergency department based on their inability to pay for services.
D. EMTALA requires that a client must be stabilized before being transferred to another facility. This ensures that the client is not placed at risk by the transfer, and the new facility is prepared to manage their care appropriately.
Correct Answer is B
Explanation
A. Make a priority list of information the client should learn: While making a priority list of information is important, it should come after assessing the client's learning needs. This ensures that the most relevant and important information is prioritized.
B. Determine the client's learning needs: The first step in planning teaching is to assess the client’s learning needs. This allows the nurse to tailor the teaching plan to the client’s level of understanding, cultural preferences, and specific concerns related to the central venous access device.
C. Obtain written information to give the client: Written information is helpful but should not be the first step. It is more effective when tailored to the client’s learning needs, which should be assessed first to ensure relevance.
D. Select a visual method to reinforce verbal teaching for the client: Visual methods can be helpful for reinforcing verbal teaching, but this step should follow the assessment of the client’s learning needs. Teaching strategy should align with the client’s preferred learning style.
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