A nurse is implementing a bladder-training program for a patient.
Which of the following actions by the assistive personnel (AP) assisting with the patient’s care should the nurse intervene?

Choice A rationale:

Stripping the client’s chest tube every 2 hours is not recommended. Stripping can create high negative pressures in the tube that can cause damage to the lung tissue. It can also lead to increased pain for the patient and is generally not a standard practice in chest tube management.

Choice B rationale:

Looping the tubing of the chest tube on the client’s bed is not a recommended practice. The chest tube should be free of loops or kinks to allow for proper drainage of air and fluid from the pleural space. Any loops or kinks in the tube can lead to accumulation of fluid or air, which can cause complications such as tension pneumothorax.

The chest tube drainage system should not be placed above the level of the client’s heart. This can lead to the backflow of blood or fluid into the pleural space, which can cause complications such as hemothorax or pleural effusion. The drainage system should always be kept below the level of the client’s chest to allow for gravity-assisted drainage.

Choice D rationale:

Taping the connections on the client’s chest tube is a recommended practice. This is done to secure the connections and prevent accidental disconnection or dislodgement of the tube. An accidental disconnection or dislodgement can lead to complications such as pneumothorax or hemothorax. Therefore, all connections should be securely taped to prevent any accidental disconnections.

Choice A rationale:

The stool guaiac test does not check for bacteria in the feces. This test is used to detect hidden (occult) blood in a stool sample. It is the most common type of fecal occult blood test (FOBT)1.

Choice B rationale:

The stool guaiac test does not check for fat in the feces. The presence of fat in the feces is usually checked by a different test called a fecal fat test. The stool guaiac test is specifically designed to detect the presence of hidden blood in the stool.

Choice C rationale:

The stool guaiac test does not check for parasites in the feces. Parasites are typically detected using a stool ova and parasites (O&P) test. The stool guaiac test is used to detect hidden blood in the stool, which could be an indication of various conditions, including colon cancer or polyps in the colon or rectum.

Choice D rationale:

The stool guaiac test checks for hidden blood in the feces. This is the correct answer. The test can find blood even if you cannot see it yourself. Occult blood in the stool may indicate colon cancer or polyps in the colon or rectum, though not all cancers or polyps bleed. If blood is detected through a fecal occult blood test, additional tests may be needed to determine the source of the bleeding. The stool guaiac test can only detect the presence or absence of blood — it can’t determine what’s causing the bleeding.