A nurse is contributing to the plan of care for a client who has a pleural chest tube with a closed drainage system. Which of the following actions should the nurse recommend for the client's care?

Maintain 30 ml sterile water in the drainage collection chamber

Place the drainage device level with the tube insertion site

Keep system tubing connections taped together.

Empty the drainage collection chamber every 4 hr.

Answer and Explanation

The Correct Answer is C

A. Maintain 30 ml sterile water in the drainage collection chamber: The sterile water is maintained in the water-seal chamber, not the drainage collection chamber. The water-seal chamber typically holds about 2 cm of water to create a one-way valve preventing air from entering the pleural space, not 30 mL in the drainage area.

B. Place the drainage device level with the tube insertion site: The drainage device should always be kept below the level of the chest tube insertion site to allow gravity to assist drainage and to prevent backflow of fluid or air into the pleural cavity, which could cause complications.

C. Keep system tubing connections taped together: Taping the system tubing connections securely helps maintain a closed system, preventing accidental disconnections that could lead to air leaks or loss of the negative pressure needed for proper lung re-expansion. This is essential for the effectiveness of chest tube management.

D. Empty the drainage collection chamber every 4 hr: The drainage collection chamber is not emptied routinely. Instead, it is replaced when full or according to facility protocol. Frequent opening of the system increases the risk of introducing infection or losing the closed negative-pressure system.

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Correct Answer is B

Explanation

A. Ringing in the ears: Ringing in the ears (tinnitus) is not a common adverse effect of enoxaparin. It is typically associated with medications like aspirin or other salicylates, not low-molecular-weight heparins like enoxaparin.

B. Black, tarry stools: Black, tarry stools are a sign of gastrointestinal bleeding, which is a serious potential adverse effect of anticoagulant medications like enoxaparin. Clients taking enoxaparin should be instructed to report this symptom immediately, as it could indicate internal bleeding.

C. Fine hand tremors: Fine hand tremors are not a known adverse effect of enoxaparin. They are more commonly associated with other medications, such as certain psychiatric drugs or neurologic conditions.

D. Diarrhea: Diarrhea is not a common adverse effect of enoxaparin. While gastrointestinal symptoms can occur with many medications, it is not a primary concern or indication for discontinuing enoxaparin.

A. "Check the water temperature with your finger" B. "Hold your baby under running water when washing his hair," C. "Cleanse the eyes from the inner canthus outward. D. "Set the water heater to 125.6 degrees Fahrenheit."

Correct Answer is C

Explanation

A. "Check the water temperature with your finger": Checking water temperature with a finger is unreliable because fingers may tolerate higher temperatures without discomfort. It is recommended to use the inside of the wrist or a thermometer to ensure the water is warm but not hot, typically around 100°F (37.8°C), to prevent burns.

B. "Hold your baby under running water when washing his hair": Holding a newborn under running water is unsafe because it can cause sudden chilling, difficulty breathing, or even slipping. Instead, caregivers should use a damp, warm washcloth or gently pour water over the baby's head while securely supporting it.

C. "Cleanse the eyes from the inner canthus outward": Cleaning from the inner to the outer canthus is correct technique because it prevents introducing contaminants into the tear duct. This motion also minimizes the spread of bacteria, reducing the risk of eye infections in the delicate eyes of a newborn.

D. "Set the water heater to 125.6 degrees Fahrenheit": A water heater set to 125.6°F presents a high risk of scald burns in infants. Safety guidelines recommend setting the water heater to no higher than 120°F (48.9°C) to reduce the risk of accidental burns during bathing or household water use.

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Area assessed	Findings
Neurological	Drowsy but easy to arouse
Vital Signs	Temperature 35.3°C (95.5° F) Heart rate 60/min Respiratory rate 16/min Blood pressure 90/60 mm Hg Oxygen saturation 94% (oxygen at 2 L/min via nasal cannula) Rates pain as 1 on 0/10 pain scale.
Integumentary	Skin cool and moist to touch.
Cardiopulmonary	Heart rate regular. Pedal pulse +1 bilateral. Lungs clear bilateral. Respirations even, nonlabored.
Abdomen	Abdomen soft, nondistended. Bowel sounds hypoactive in all four quadrants. 2x2 gauze with a clear transparent dressing intact to right lower and upper abdominal quadrant. Moderate amount of sanguineous drainage noted on the lower dressing

A nurse is contributing to the plan of care for a client who has a pleural chest tube with a closed drainage system. Which of the following actions should the nurse recommend for the client's care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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