A patient arrives at the emergency department with a stab wound to the chest.

The healthcare provider places two chest tubes to drain air and blood from the patient’s thoracic cavity.

Where should the nurse place the system?

Attached to the foot of the bed.

Below the level of the patient’s chest.

Along the side of the patient’s knee.

At the level of the patient’s clavicle.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Attaching the chest tube system to the foot of the bed is not recommended. This position could potentially cause the system to tip over or become disconnected, which could lead to complications such as pneumothorax or hemothorax.
Choice B rationale
The chest tube system should be placed below the level of the patient’s chest. This allows for gravity-assisted drainage of air and fluid from the thoracic cavity, which is crucial for the patient’s recovery. The system works on a water seal that prevents air or fluid from entering the pleural space. Placing the system below the chest level ensures that the water seal is maintained, preventing backflow of fluid or air into the pleural space.
Choice C rationale
Placing the system along the side of the patient’s knee is not appropriate. This position does not facilitate effective drainage of air and fluid from the thoracic cavity. It could also lead to discomfort and potential dislodgement of the system.
Choice D rationale
Placing the system at the level of the patient’s clavicle is not recommended. This position is too high and could disrupt the water seal, leading to ineffective drainage and potential complications.

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Correct Answer is A

Explanation

Choice A rationale
The abdomen is a common site for subcutaneous injections because it allows for consistent absorption. The area above the iliac crest is often used because it is easy to access and usually has enough subcutaneous tissue for the injection.
Choice B rationale
A 1-inch needle is typically too long for a subcutaneous injection. A shorter needle (usually 1/2 to 5/8 inch) is usually used to ensure the medication is delivered to the subcutaneous tissue.
Choice C rationale
A 22-gauge needle is typically too large for a subcutaneous injection. Smaller gauge needles (usually 25-27 gauge) are usually used for subcutaneous injections.
Choice D rationale
Massaging the injection site after administration of heparin is not recommended. It can cause the medication to be absorbed too quickly and can also lead to bruising.

A. Increase the feeding to 35ml/hr. B. Decrease the feeding to 10ml/hr. C. Continue the feeding as ordered. D. Hold the feeding and notify the doctor.

Correct Answer is C

Explanation

A gastric residual volume of 10ml is not considered high. The client is receiving 60ml/hr of feeding, which is within normal limits. Therefore, the nurse should continue the feeding as ordered.

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A patient arrives at the emergency department with a stab wound to the chest. The healthcare provider places two chest tubes to drain air and blood from the patient’s thoracic cavity. Where should the nurse place the system?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer heparin subcutaneously to a client. Which action by the nurse is appropriate?

Correct Answer is A

Explanation

The nurse is assessing tube feeding residual amounts and finds 10ml of residual. The client is receiving 60ml/hr of feeding. What action should the nurse take?

Correct Answer is C

Explanation

A nurse is advising a client who is taking furosemide and has a serum potassium level of 3.1 mEq/L. Which food should the nurse recommend the client to incorporate into their daily diet?

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A patient arrives at the emergency department with a stab wound to the chest.

The healthcare provider places two chest tubes to drain air and blood from the patient’s thoracic cavity.

Where should the nurse place the system?