A nurse is caring for a client with a chest tube. Which action should the nurse take?

Position the collection device below the level of the chest.

Clamp the tube when providing care activities.

Apply an occlusive dressing over the chest tube site.

Empty the chest tube collection chamber every shift.

Answer and Explanation

The Correct Answer is A

Choice A reason: Positioning the collection device below the level of the chest is crucial to ensure proper drainage of air or fluid from the pleural space. This positioning uses gravity to facilitate drainage and prevent backflow into the pleural cavity, which could lead to complications such as pneumothorax or pleural effusion. The collection device should always be kept below the chest level to maintain effective drainage.

Choice B reason: Clamping the chest tube is generally not recommended unless specifically ordered by a physician or during certain procedures. Clamping can lead to a buildup of air or fluid in the pleural space, increasing the risk of tension pneumothorax. It is essential to keep the chest tube unclamped to allow continuous drainage and prevent complications.

Choice C reason: Applying an occlusive dressing over the chest tube site is necessary to prevent air from entering the pleural space and to secure the tube. However, this is not the primary action related to the positioning of the collection device. The occlusive dressing helps maintain the integrity of the chest tube insertion site and prevents infection.

Choice D reason: Emptying the chest tube collection chamber every shift is not a standard practice. The collection chamber should be monitored and emptied as needed based on the volume of drainage and the specific protocols of the healthcare facility. Regular monitoring is essential, but unnecessary emptying can disrupt the closed system and increase the risk of infection.

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Correct Answer is C

Explanation

Choice A Reason:

A pureed diet consists of foods that are blended to a smooth consistency. This type of diet is typically recommended for clients who have severe swallowing difficulties or are at risk of aspiration. While it can be easier to consume for those with significant dental issues, it may not provide the variety and texture that a mechanical soft diet offers, which can be more satisfying and nutritionally adequate for someone with multiple cavities and missing teeth.

Choice B Reason:

A soft diet includes foods that are easy to chew and swallow but are not necessarily blended or pureed. This diet is often recommended for clients recovering from surgery or those with mild chewing difficulties. However, for a client with multiple cavities, chipped, and missing teeth, a soft diet might still pose challenges in terms of chewing and could lead to discomfort or inadequate nutrition.

Choice C Reason:

A mechanical soft diet is specifically designed for individuals who have difficulty chewing but do not require pureed foods. This diet includes foods that are easy to chew and swallow, such as ground meats, cooked vegetables, and soft fruits. It provides a balance of texture and nutrition, making it the most appropriate choice for a client with multiple cavities, chipped, and missing teeth. This diet helps ensure the client can eat comfortably and maintain adequate nutrition.

A. Age dose of pain medication B. Correct method of administering your own pain medication C. Operator can push the PCA button for you if you are asleep D. The pain medication is delivered at your nose

Correct Answer is A

Explanation

Choice A Reason:

Age dose of pain medication refers to adjusting the dosage of pain medication based on the client’s age. Elderly clients often have different pharmacokinetics and pharmacodynamics compared to younger individuals, which means they may require lower doses of medication to achieve the same effect. This adjustment helps to prevent overmedication and potential side effects, ensuring safe and effective pain management for elderly clients.

Choice B Reason:

Correct method of administering your own pain medication is important for clients who are capable of self-administering their medication. However, this choice does not directly address the issue of balance deficit and the need for an assistive device. While proper medication administration is crucial, it is not the primary concern in this scenario.

Choice C Reason:

Operator can push the PCA button for you if you are asleep is not an appropriate practice. Patient-controlled analgesia (PCA) is designed to allow clients to self-administer pain medication as needed. Allowing someone else to push the button can lead to overmedication and potential complications. This choice does not address the need for an assistive device for balance deficit.

Choice D Reason:

The pain medication is delivered at your nose is not a standard method of pain medication administration. This choice is incorrect and does not relate to the client’s need for an assistive device for balance deficit. Pain medication is typically administered orally, intravenously, or through other appropriate routes, but not through the nose.

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A nurse is caring for a client with a chest tube. Which action should the nurse take?

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