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 C

Explanation

A. Urine output should increase with adequate fluid replacement, not decrease.
B. Weight may increase with fluid resuscitation due to fluid accumulation; a decrease is not a reliable sign of adequate resuscitation in the acute phase.
C. Heart rate. In burn patients, tachycardia is often a compensatory response to hypovolemia. A decrease in heart rate indicates improving circulatory volume and perfusion, suggesting effective fluid resuscitation.
D. Blood pressure should increase or stabilize with adequate fluids; a decrease suggests inadequate perfusion or ongoing hypovolemia.

A. Hold administration of analgesics B. Keep blood pressure elevated to promote perfusion C. Administer antibiotics as prescribed D. Keep blood pressure within ordered parameters

Correct Answer is D

Explanation

A. Analgesics are important to manage pain and reduce stress, which can help prevent aneurysm rupture.
B. Keeping blood pressure elevated increases the risk of aneurysm rupture and is not appropriate.
C. Antibiotics are not routinely indicated unless there is an infection.
D. Controlling blood pressure reduces stress on the aneurysm wall, minimizing the risk of rupture.

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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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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