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.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is C
Explanation
Neisseria gonorrhoeae is a sexually transmitted infection that is reportable to public health authorities due to its potential for spreading rapidly within a population and its significant public health implications. Reporting cases of Neisseria gonorrhoeae infection allows for appropriate monitoring, treatment, and control measures to be implemented to prevent further transmission and protect public health.
Sarcoptes scabiei, which causes scabies, is a contagious skin infestation but is not typically a reportable condition to the state health department.
Human papillomavirus (HPV) is a common sexually transmitted infection, but it is not generally reportable unless it is associated with certain high-risk strains and leads to specific conditions such as cervical cancer.
Impetigo contagiosa, a bacterial skin infection, is not usually a reportable condition unless there is an outbreak or unusual circumstances warranting public health intervention.
Correct Answer is A
Explanation
Allowing the toddler to explore and handle the equipment, such as a stethoscope or blood pressure cuff, can help familiarize them with the objects and reduce anxiety. It can be done under the supervision of the nurse to ensure safety.
Starting the examination with routine immunizations can be helpful because it allows the child to get through potentially uncomfortable or distressing procedures early on. It can also create a positive association between the examination and a sense of relief after receiving vaccinations. While it is important to provide age-appropriate explanations to the toddler, it's essential to keep the explanations simple and concise. Using child-friendly language and demonstrating the procedure using dolls or toys can help the toddler understand what will happen during the examination.
Instead of completely undressing the toddler, it is generally more comfortable and less distressing to only partially undress them. For example, the nurse can ask the caregiver to remove the toddler's shirt while leaving the pants on. This approach helps maintain the child's sense of security and provides a level of modesty.
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