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 C
Explanation
Explanation:
Displacement is a defense mechanism in which an individual redirect their emotions or impulses from their original target to a less threatening or safer target. In this scenario, the client yells at the nurse when medication changes are prescribed by the provider. The client may be feeling angry or frustrated about the medication changes but is unable to express those emotions directly towards the provider. Instead, the client displaces those feelings onto the nurse, who may be seen as a safer or more accessible target. The yelling behavior directed at the nurse is a way for the client to release and express their emotions indirectly.
Let's briefly discuss the other defense mechanisms mentioned:
A- Conversion: Conversion involves the expression of psychological distress or conflict through physical symptoms or ailments. It is not applicable in this scenario since the client's behavior does not involve physical symptoms.
B- Splitting: Splitting is a defense mechanism characterized by a black-and-white thinking pattern, where individuals perceive others or situations as all good or all bad. It does not directly apply in this scenario as the client's behavior is not indicative of splitting.
D- Sublimation: Sublimation is a defense mechanism in which an individual channel their unacceptable or potentially harmful impulses into socially acceptable outlets, such as creative or productive activities. It is not evident in this scenario as the client's behavior does not involve transforming the emotions into a more positive or socially acceptable form.

Correct Answer is ["A","C"]
Explanation
Varicella zoster is highly contagious, and airborne precautions should be implemented. Assigning the client to a negative pressure airflow room helps prevent the spread of the virus to others by containing and filtering the air within the room.
In addition to airborne precautions, contact precautions should also be implemented. This includes using gloves and gowns when providing care to the client to minimize direct contact with infectious materials.

The other options listed are not appropriate interventions for a client with varicella zoster: While it is important to minimize close contact with an infectious client, varicella zoster is primarily transmitted through airborne droplets. Visitors should follow the appropriate precautions, such as wearing masks and adhering to hand hygiene, rather than just maintaining a certain distance.
Aspirin should not be given to clients with varicella zoster, especially children, due to the risk of developing Reye's syndrome. Reye's syndrome is a rare but serious condition that can cause swelling in the liver and brain. Acetaminophen (paracetamol) is typically recommended for managing fever in clients with varicella zoster.
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