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.

Answer and Explanation

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.

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Correct Answer is ["1971"]

Explanation

Face: 4.5%

Left arm: 9%

Total TBSA = 4.5 + 9 = 13.5%

Fluid needed in 24 hours = 4 mL × 73 kg × 13.5 = 3942 mL (rounded)

Half of this is given in the first 8 hours: 3942 ÷ 2 = 1971 mL

A. Assess ventilator settings every 48 hours. B. Position the head of the client's bed in the flat position. C. Brush the client's teeth with a suction toothbrush routinely and as needed. D. Turn the client every 8 hours.

Correct Answer is C

Explanation

A. Ventilator settings should be assessed frequently, not just every 48 hours.
B. The head of the bed should be elevated (30–45 degrees), not flat, to reduce aspiration risk.
C. Maintaining oral hygiene reduces the risk of ventilator-associated pneumonia by minimizing bacterial colonization.
D. Turning the client more frequently than every 8 hours (typically every 2 hours) is standard to prevent complications but is less directly related to preventing ventilator-associated pneumonia compared to oral care.

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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

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Naxlex Comprehensive Predictor Exams

client who suffered burn injuries to their face and entire left arm is to receive lactated ringers. The client weighs 73 kg. How much fluid will be infused for the first 8 hours? (Round to the nearest whole number).

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Explanation

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