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?
Ensure the device is kept below the level of the client's chest.
Clamp the chest tube every 4 hr.
Place the client in a supine position.
Empty the collection chamber every 8 hr.
The Correct Answer is A
Ensuring the device is kept below the level of the client's chest is important to ensure that the drainage system functions properly by allowing the fluid and air to flow downhill. Placing the device below the level of the chest helps facilitate gravity drainage.
Continuous suction is required for proper functioning of the chest tube drainage system. Clamping the chest tube can disrupt the suction and impede the removal of air or fluid from the pleural space. Only in specific circumstances, such as when changing the drainage system or assessing for air leaks, may the healthcare provider request a temporary clamping of the chest tube.
Positioning the client semi-Fowler's, with the head of the bed elevated, can help promote lung expansion and improve oxygenation. The specific positioning may vary depending on the client's condition and the healthcare provider's recommendations.
The nurse should empty the collection chamber as per the facility's protocol, which typically includes monitoring the drainage and emptying it when it reaches a certain level. Regular emptying of the collection chamber helps maintain proper functioning of the chest tube system and allows for accurate measurement of drainage output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Explanation
A. Increased erythrocyte sedimentation rate
A. Increased erythrocyte sedimentation rate (ESR) is a non-specific marker of inflammation in the body. In the presence of an infection, the ESR tends to rise due to increased levels of acute-phase reactants, such as fibrinogen and globulins. However, it is important to note that an increased ESR alone does not diagnose a specific infection but rather indicates the presence of inflammation or infection.
Decreased platelets in (option B) should not be included because they are not typically associated with infection. Low platelet levels (thrombocytopenia) may occur due to various reasons, such as certain medications, immune disorders, or bone marrow problems, but they are not directly linked to infections.
Increased iron level in (option C) should not be included because it is not a typical finding in an active infection. In fact, during an infection, iron levels tend to decrease in response to the body's efforts to withhold iron from pathogens, as most microorganisms require iron for their growth and survival.
Decreased haemoglobin in (option D) should not be included because it is not directly indicative of an infection. A decrease in hemoglobin levels may be associated with conditions such as anaemia, blood loss, or certain chronic diseases, but it is not a specific marker for infection.
Correct Answer is C
Explanation
Explanation
C. I will wear a clean pair of cotton socks each day
Wearing a clean pair of cotton socks each day is an important aspect of foot care for individuals with diabetes. Here's why the other options are incorrect:
Using iodine to disinfect cuts on the feet in (option A) is not recommended for individuals with diabetes as it can be irritating to the skin and delay wound healing. It is best to clean cuts with mild soap and water and consult a healthcare professional for proper wound care.
Soaking feet in warm water every morning in (option B) is not recommended for individuals with diabetes. Prolonged exposure to water can increase the risk of dryness and cracking, leading to skin breakdown and infections. It is advisable to avoid prolonged soaking and to dry the feet thoroughly after washing.
Removing ingrown toenails at home in (option D) is not recommended for individuals with diabetes. Attempting to do so can result in injury and increase the risk of infection. It is important for individuals with diabetes to seek professional care for any foot-related concerns, including ingrown toenails.
In summary, the correct statement is C: "I will wear a clean pair of cotton socks each day." This demonstrates an understanding of the importance of foot hygiene and minimizing moisture to reduce the risk of fungal infections and foot complications for individuals with diabetes.
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