A nurse is caring for a client who has a three-chamber chest tube system. Which of the following actions should the nurse take?
Ensure 2 cm (0.8 in) of water is in the water seal chamber.
Check the patency of the tubing every 2 hr.
Keep the drainage system above the level of the client's chest.
Empty the collection chamber every 8 hr.
The Correct Answer is A
A. Ensure 2 cm (0.8 in) of water is in the water seal chamber. This is correct because maintaining the correct water level in the water seal chamber is essential for proper functioning of the chest tube system, as it prevents air from entering the pleural space.
B. Check the patency of the tubing every 2 hr. This is incorrect because continuous monitoring is required, and patency should be ensured at all times, not just at set intervals. However, frequent assessments are important.
C. Keep the drainage system above the level of the client's chest. This is incorrect because the drainage system should be kept below chest level to allow gravity drainage and prevent backflow into the pleural space.
D. Empty the collection chamber every 8 hr. This is incorrect because the collection chamber should only be emptied when full, following facility protocol, to maintain an accurate record of drainage output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Lubricating the catheter with water-soluble gel is important but is done after preparing the sterile field.
B. Attaching a prefilled syringe to the catheter inflation hub is performed after insertion to secure the catheter, not before.
C. Cleansing the client’s meatus with antiseptic solution is essential for infection prevention but is done after the sterile field is set up.
D. Positioning the sterile drape while leaving the perineum exposed is the first step because it maintains a sterile field and provides a clean working area for catheter insertion. This prevents contamination and reduces the risk of infection.
Correct Answer is C
Explanation
A. Yogurt and granola is not appropriate because granola is hard and can be difficult to swallow, increasing the risk of aspiration.
B. Wheat toast with butter is not appropriate because toast is dry and can be difficult to chew and swallow, posing a choking hazard.
C. Pancakes with syrup are soft and easy to chew, making them a suitable choice for a mechanically altered diet. The syrup adds moisture, further aiding swallowing.
D. Banana and nut muffin is not appropriate because muffins can be dry and crumbly, and nuts are a choking hazard for clients with dysphagia.
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