A nurse is providing care to a client who has a chest tube. Which of the following should the nurse expect to implement?
Adjust tubing to form a coil and hang from chest tube to drainage chamber
Keep drainage system slightly above client chest level.
Assess vital signs every 30 min for the first 3 hr.
Assess for the presence of bubbling with exhalation or cough.
The Correct Answer is C
A. Tubing should be kept straight and free of kinks or coils to ensure proper drainage, not coiled or hung.
B. The drainage system should be kept below the client’s chest level to prevent backflow of fluid into the pleural space.
C. Assessing vital signs every 30 minutes for the first 3 hours is appropriate to monitor for complications after chest tube insertion.
D. Bubbling in the water seal chamber is expected with coughing or exhalation; continuous bubbling may indicate an air leak, so assessing for bubbling is important but not specifically with exhalation or cough only.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Increased urine output is not typical; DIC can cause decreased kidney perfusion leading to low urine output.
B. Petechiae are small pinpoint hemorrhages caused by the widespread clotting and consumption of platelets in DIC, making this an expected finding.
C. Bradycardia is not specifically associated with DIC.
D. Decreased respirations are not a direct manifestation of DIC.
Correct Answer is C
Explanation
A. The catheter site should be cleansed using a circular motion, starting at the exit site and moving outward, not a side-to-side motion, to prevent introducing microorganisms.
B. Taping down only the corners does not adequately secure the dressing. All edges should be sealed to reduce the risk of infection.
C. Placing a mask on the client (and the nurse) during dressing changes helps prevent contamination of the peritoneal catheter site, which is highly susceptible to infection. This is an essential aseptic practice.
D. An occlusive dressing is not typically recommended over peritoneal dialysis catheter sites, as it can trap moisture and increase the risk of infection. A sterile gauze dressing is generally preferred.
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