The drainage in the chest tube of a client with emphysema has changed from viscous green to clear watery fluid. Which action is best for the nurse to tak?

Schedule a portable chest x-ray per PRN protocol.

Maintain the current IV antibiotic schedule.

Obtain a specimen of the drainage for culture.

"Milk" the tube to remove any clots.

Answer and Explanation

The Correct Answer is C

A.   A chest x-ray can be useful to assess for complications or changes in lung status, such as pneumothorax, pleural effusion, or changes in lung volume. However, the change in drainage color from viscous green to clear watery fluid may not immediately warrant an x-ray unless there are additional clinical concerns or symptoms suggesting a need for imaging.
B.   Continuing the IV antibiotic schedule is important if there is an ongoing infection that needs treatment. However, if the change in drainage is significant and suggests a potential change in the underlying condition or complication, it’s important to evaluate the cause of the change rather than solely relying on antibiotics.
C.   Obtaining a specimen of the drainage for culture is a valuable action if there is concern about infection or if the drainage characteristics have changed unexpectedly. Clear, watery fluid could indicate the presence of serous fluid or a change in the nature of the drainage, potentially due to infection or resolution of an infection.
D.   “Milking” or stripping the chest tube is not recommended as a routine practice because it can create negative pressure and potentially damage the pleural tissues or exacerbate issues. Additionally, the change in the drainage from viscous green to clear watery fluid does not necessarily indicate that clots are present or that tube milking would be helpful.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. The sudden onset of flashing lights and floaters can be a symptom of a detached retina, a serious eye condition that requires immediate medical attention.
B. This is incorrect. The client should not engage in any activities until the condition is evaluated by a healthcare professional.
C. While rest might seem appropriate, the client should seek immediate medical attention due to the potential seriousness of the symptoms.
D. Warm compresses are not indicated for this condition, and the client should seek immediate medical attention.

A. Ask the client to rate her pain on a scale from 0 to 10. B. Teach the client to keep the leg elevated C. Treat with ice then apply an elastic bandage wrap. D. Check the leg for warmth and erythema.

Correct Answer is D

Explanation

A. While pain assessment is important, it's not the priority in this situation. Pain can be present in various conditions, and it doesn't necessarily indicate DVT.
B. Elevating the leg can help reduce swelling but is not the initial action. The nurse needs to rule out a serious condition like DVT first.
C. Applying ice and an elastic bandage might be appropriate for some types of swelling but is not the correct initial action for a sudden, unilateral leg swelling.
D. The client presents with sudden, unilateral leg swelling, which is a red flag for deep vein thrombosis (DVT). DVT is a serious condition that can lead to pulmonary embolism. Therefore, the nurse's priority is to assess for signs of inflammation, which are warmth and erythema.

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The drainage in the chest tube of a client with emphysema has changed from viscous green to clear watery fluid. Which action is best for the nurse to tak?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Correct Answer is D

Explanation

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