A nurse is caring for a client who has a newly inserted chest drainage system with a water seal. Which of the following actions should the nurse
take?
Keep the collection device below the level of the client's chest.
Lay the client flat to avoid leaks in the tubing.
Clamp the tube when the client is ambulating...
Coil the tubes carefully to prevent kinking.
The Correct Answer is A
A. Keeping the collection device below the level of the client’s chest prevents backflow of drainage into the pleural space.
B. The client should be positioned to promote lung expansion, often sitting up, not necessarily flat.
C. Clamping the chest tube is generally avoided as it can cause tension pneumothorax or other complications.
D. Tubing should be kept straight without coiling to prevent kinking and obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Checking pedal pulses assesses circulation but will not help identify the cause of muscle spasms in this context.
B. Muscle spasms following a thyroidectomy may indicate hypocalcemia, a common complication due to accidental removal or damage to the parathyroid glands during surgery. This electrolyte imbalance can lead to neuromuscular excitability and tetany, which requires prompt recognition and treatment.
C. Requesting a relaxant may mask symptoms without addressing the underlying cause, delaying appropriate treatment.
D. Administering potassium is not appropriate unless hypokalemia is confirmed; muscle spasms in this scenario are more likely due to low calcium, not potassium.
Correct Answer is D
Explanation
A. Controlling impulsive behavior is more commonly associated with right hemispheric strokes due to impaired judgment and spatial awareness.
B. Improving left-side motor function would be a goal for a right hemispheric CVA because motor deficits occur on the side opposite the brain injury.
C. Loss of depth perception is typically a problem with right hemispheric damage affecting spatial-perceptual skills.
D. Left hemispheric strokes often affect language centers, leading to aphasia. Therefore, a primary rehabilitation goal is improving communication abilities.
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