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

Obtain cultures from the chest tube site before insertion.

Apply pressure dressing to the wound site after insertion.

Administer antibiotics to the patient before the procedure.

Monitor vital signs and pain level after the chest tube insertion.

Instruct the patient to take deep breaths during the insertion.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Obtaining cultures from the chest tube site before insertion is not a standard nursing action during chest tube preparation. Cultures are usually taken if there is an infection or concern after the insertion.

Choice B rationale:

Applying a pressure dressing to the wound site after chest tube insertion is not a recommended practice. Airtight dressing can lead to tension pneumothorax. Instead, a sterile occlusive dressing is typically applied.

Choice C rationale:

Administering antibiotics to the patient before the procedure is not a standard nursing action during chest tube preparation. Antibiotics are usually prescribed if there is an infection after the insertion.

Choice D rationale:

Monitoring vital signs and pain level after chest tube insertion is essential to assess the patient's response to the procedure and to identify any complications, such as pneumothorax, bleeding, or infection.

Choice E rationale:

Instructing the patient to take deep breaths during the insertion is not appropriate because chest tube insertion is a sterile procedure, and patients are usually not conscious during the process. The insertion site is anesthetized, and deep breaths could compromise sterile technique and increase the risk of infection.

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Correct Answer is ["A","C","E"]

Explanation

Choice A rationale:

The nurse should obtain a physician's order and informed consent from the patient before removing the chest tube. Rationale: Chest tube removal is a medical procedure that requires a physician's order, and obtaining informed consent ensures that the patient is aware of the procedure and its potential risks.

Choice B rationale:

Instructing the patient to exhale forcefully during the removal is not necessary and may even be harmful. Rationale: The Valsalva maneuver, which involves forceful exhalation, can increase intrathoracic pressure and may lead to complications like pneumothorax during chest tube removal. Therefore, this action should be avoided.

Choice C rationale:

Monitoring the patient's respiratory status and vital signs after the removal is essential. Rationale: After chest tube removal, it is crucial to monitor the patient for signs of respiratory distress, such as shortness of breath or decreased oxygen saturation, and vital signs to detect any complications promptly.

Choice D rationale:

Applying an occlusive dressing with petroleum gauze over the wound site after removal is not the standard practice. Rationale: After chest tube removal, the wound site is typically left open to allow for the drainage of any residual air or fluid. Applying an occlusive dressing can trap air or fluid, leading to complications.

Choice E rationale:

Preparing sterile supplies such as a suture removal kit before the procedure is not necessary for chest tube removal. Rationale: Chest tube removal does not require suture removal or sterile supplies. It is a relatively simple procedure that involves removing the chest tube after ensuring proper lung re-expansion and securing the wound with an appropriate dressing.

A. Keep the drainage system above the chest level. B. Clamp the tubing for an extended period to prevent leaks. C. Ensure adequate and stable water levels in the water-seal and suction-control chambers. D. Milk or strip the tubing regularly to enhance drainage. E. Keep the tubing free of kinks, loops, or dependent areas.

Correct Answer is ["C","E"]

Explanation

Choice A rationale:

Keeping the drainage system above the chest level is incorrect because the drainage system should be placed below the chest level to facilitate proper drainage of fluids and air.

Choice B rationale:

Clamping the tubing for an extended period to prevent leaks is incorrect. Chest tubes should never be clamped for an extended period as it can lead to a dangerous buildup of pressure within the pleural space and impair proper drainage.

Choice C rationale:

Ensuring adequate and stable water levels in the water-seal and suction-control chambers is correct. Maintaining appropriate water levels is essential for maintaining the proper functioning of the chest tube system, ensuring that it can effectively remove air and fluid from the pleural space.

Choice D rationale:

Milking or stripping the tubing regularly to enhance drainage is incorrect. This practice is outdated and can cause damage to the chest tube, leading to potential complications. The tubing should not be manipulated in this manner.

Choice E rationale:

Keeping the tubing free of kinks, loops, or dependent areas is correct. Any kinks, loops, or dependent areas can obstruct the flow of fluids and air within the chest tube system, impairing its functionality.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to remove a chest tube from a patient. Which of the following actions should the nurse take during the removal procedure? Select all that apply:

Correct Answer is ["A","C","E"]

Explanation

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Correct Answer is ["C","E"]

Explanation

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