A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?

Clamp the chest tube every 4 hr.

Place the client in a supine position.

Ensure the device is kept below the level of the client's chest.

Empty the collection chamber every 8 hr.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Clamp the chest tube every 4 hr: Routine clamping of a chest tube is not recommended, as it can lead to tension pneumothorax by trapping air in the pleural space. Clamping is only done briefly and for specific reasons, such as system checks or before removal.

B. Place the client in a supine position: The supine position can impair lung expansion and hinder drainage from the pleural space. Clients with a chest tube are best positioned in semi-Fowler’s or high-Fowler’s to promote ventilation and facilitate drainage.

C. Ensure the device is kept below the level of the client's chest: Keeping the drainage system below chest level promotes gravity-assisted drainage and prevents backflow of air or fluid into the pleural space, which could compromise lung re-expansion.

D. Empty the collection chamber every 8 hr: The collection chamber is not emptied; it is replaced when full. Opening the system introduces infection risk and disrupts the closed drainage system necessary for maintaining negative pressure.

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Correct Answer is B

Explanation

Rationale:

A. "We've seen steady improvement in other clients who are depressed.": While this may sound reassuring, it provides generalized information that may create unrealistic expectations. It does not address the partner’s specific concerns or open up a dialogue for emotional support or understanding.

B. "Tell me what you know about depression,": This response encourages open communication and assesses the partner's understanding of the condition. It allows the nurse to provide accurate, individualized information and emotional support based on what the partner already knows or believes.

C. "No one really knows the answer to that question.": Though factually true, this statement may seem dismissive or lacking empathy. It does not invite discussion or support the emotional needs of the partner, who is likely feeling uncertain or overwhelmed.

D. "The important thing is that he gets better, not how long it takes.": This response minimizes the partner’s valid concern about recovery time. It may come across as invalidating and does not provide helpful or therapeutic communication.

A. Cleanse the most contaminated wounds first. B. Use hydrogen peroxide for wound cleaning C. Perform dressing changes every other day. D. Apply dressings with sterile gloves

Correct Answer is D

Explanation

Rationale:

A. Cleanse the most contaminated wounds first: Wound care should begin with the cleanest area and progress to the most contaminated to reduce the risk of cross-contamination. Starting with the dirtiest wounds may spread infection to cleaner sites.

B. Use hydrogen peroxide for wound cleaning: Hydrogen peroxide can damage healthy tissue and delay healing. It is generally not recommended for burn wound care due to its cytotoxic effects on granulating tissue.

C. Perform dressing changes every other day: Dressing frequency depends on the type of burn, wound condition, and healthcare provider's orders. Some burn wounds require daily or even more frequent changes to prevent infection and promote healing.

D. Apply dressings with sterile gloves: Sterile technique is critical in burn care to prevent infection. Using sterile gloves during dressing application ensures the wound is protected from external contaminants during a vulnerable healing phase.

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A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who was recently diagnosed with depression. The client's partner asks when he will get better. Which of the following is an appropriate response by the nurse?

Correct Answer is B

Explanation

A nurse is assisting with the plan of care for a client who has burns to his lower extremities. Which of the following actions should the nurse include in the plan?

Correct Answer is D

Explanation

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