A nurse is educating a patient and their family about chest tube care. What instructions should the nurse include?

"You should keep the drainage system below the chest level at all times.".

"Deep breathing and coughing exercises are not necessary while the chest tube is in place.".

"Notify the physician immediately if you observe any subcutaneous emphysema around the chest tube site.".

"You can expect the drainage color to change from serosanguineous to bright red during the recovery process.".

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The nurse should instruct the patient and their family to keep the drainage system below the chest level at all times. This positioning helps ensure proper drainage of fluid or air from the chest, preventing any backflow or obstruction in the system. Gravity assists in maintaining the drainage flow, promoting the effectiveness of the chest tube.

Choice B rationale:

Deep breathing and coughing exercises are essential while the chest tube is in place. These exercises help prevent complications such as atelectasis and pneumonia by promoting lung expansion and clearing secretions. The patient should be encouraged to perform these exercises as directed by the healthcare provider.

Choice C rationale:

The nurse should educate the patient and their family to notify the physician immediately if they observe any subcutaneous emphysema around the chest tube site. Subcutaneous emphysema is a potential complication of chest tube placement, indicating air leakage into the tissues. Prompt notification allows for timely intervention to prevent further complications.

Choice D rationale:

The nurse should inform the patient that the drainage color may change from serosanguineous (pale, pink, or slightly bloody) to bright red during the recovery process. Initially, the drainage may be bloody, but as healing progresses, it should become clearer. However, if the drainage suddenly becomes bright red, it could indicate active bleeding, and the healthcare provider should be notified immediately.

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Correct Answer is B

Explanation

Choice A rationale:

Walking barefoot at home is not advisable for a client with diabetes. It can increase the risk of injury and foot complications, as individuals with diabetes may have reduced sensation in their feet, making it difficult to detect injuries promptly.

Choice B rationale:

"Inspect your feet daily, especially between the toes.”. This is the correct choice. Daily foot inspection is crucial for early detection of any signs of injury, infection, or changes in the skin. Early intervention can prevent more severe foot complications in individuals with diabetes.

Choice C rationale:

Applying heating pads to the feet for warmth in cold weather is not recommended for individuals with diabetes, as they may have reduced sensitivity to temperature changes and can accidentally burn their feet.

Choice D rationale:

Using adhesive tape to treat blisters or sores on the feet is not advised. Any wounds or foot issues should be assessed and treated by a healthcare professional to prevent infection and promote proper healing.

A. Administer diuretics to reduce the fluid accumulation. B. Prepare for needle decompression or chest tube insertion. C. Position the client in a Trendelenburg position to facilitate breathing. D. Instruct the client to take slow, deep breaths to prevent further complications.

Correct Answer is B

Explanation

Choice A rationale:

Administering diuretics to reduce fluid accumulation is incorrect. Severe dyspnea, absent breath sounds, and jugular venous distension indicate a potential tension pneumothorax or hemothorax, which requires prompt action, and diuretics would not address the underlying issue.

Choice B rationale:

Preparing for needle decompression or chest tube insertion is the appropriate nursing action. The client's symptoms of severe dyspnea, absent breath sounds, jugular venous distension, and increased intrathoracic pressure suggest a possible tension pneumothorax or hemothorax. Immediate decompression with a large-bore needle or insertion of a chest tube is necessary to relieve pressure and restore lung function.

Choice C rationale:

Positioning the client in a Trendelenburg position to facilitate breathing is incorrect. In the case of increased intrathoracic pressure, this position can further compromise respiratory function and is not recommended.

Choice D rationale:

Instructing the client to take slow, deep breaths to prevent further complications is incorrect. The client's condition requires urgent medical intervention, and slow, deep breaths would not address the acute issue of increased intrathoracic pressure and compromised lung function.

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A nurse is educating a patient and their family about chest tube care. What instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing education to a client with diabetes on foot care. The nurse should include which statement to promote foot health?

Correct Answer is B

Explanation

A client with a chest tube reports severe dyspnea, absent breath sounds on the affected side, and jugular venous distension. The nurse assesses increased intrathoracic pressure. What is the appropriate nursing action?

Correct Answer is B

Explanation

A nurse is responsible for chest tube care and management. Which of the following actions should the nurse perform to maintain chest tube function? Select all that apply:

A nurse is preparing a patient for chest tube insertion. Which of the following nursing actions should the nurse take during the preparation process?

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A client with a chest tube shows signs of infection, such as fever, chills, increased white blood cell count, and purulent drainage. What intervention should the nurse prioritize?

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A client diagnosed with diabetes asks the nurse about dietary recommendations. The nurse should advise the client to limit the intake of which of the following foods? Select all that apply:

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