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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Double vision at 34 weeks of gestation is a potential sign of preeclampsia, which can lead to severe complications such as seizures (eclampsia), stroke, or organ damage. This client requires immediate assessment.
B. Leg cramps are common in late pregnancy due to pressure on nerves and changes in circulation. This is not an urgent concern.
C. Excessive salivation (ptyalism) is benign and can occur in early pregnancy due to hormonal changes. It does not require immediate assessment.
D. Periodic finger numbness is often due to carpal tunnel syndrome, a common non-urgent condition in pregnancy caused by fluid retention.

A. Administer the prescribed number of drops B. Apply gentle pressure to the client's punctum C. Tilt the client's head backward toward the ceiling D. Pull the client's lower lid down with the nondominant hand E. Verify the clarity and color of the eye drops

Correct Answer is E,C,D,A,B

Explanation

Verify the clarity and color of the eye drops. Ensuring the medication is not expired or contaminated is the first step in safe administration.
Tilt the client's head backward toward the ceiling. This position helps prevent the drops from draining out of the eye.
Pull the client's lower lid down with the nondominant hand. This creates a small pocket for the eye drops to be instilled properly.
Administer the prescribed number of drops. The medication should be placed in the conjunctival sac, not directly on the cornea.
Apply gentle pressure to the client's punctum. This prevents systemic absorption by blocking the nasolacrimal duct and reduces systemic side effects.

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A nurse is caring for a client who has a three-chamber chest tube system. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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