The nurse is caring for a client who has a pneumothorax and a water-seal chest tube drainage system to suction. Which of the following actions should the nurse take?
Add tap water as needed to the suction control chamber.
Maintain the drainage container below the level of the client's chest.
Empty the collection container every shift.
Clamp the chest tubes if it becomes disconnected
The Correct Answer is B
A. Add tap water as needed to the suction control chamber.
This is not the correct action. The suction control chamber of a water-seal chest tube drainage system is typically filled with sterile water to the prescribed level by the healthcare provider during the initial setup. Adding tap water to the suction control chamber can disrupt the balance of the system and affect the prescribed suction level. The nurse should not add tap water without specific instructions from the healthcare provider.
B. Maintain the drainage container below the level of the client's chest.
This is the correct action. In a water-seal chest tube drainage system, it's important to keep the drainage container below the level of the client's chest. This positioning allows gravity to assist in the drainage of air or fluid from the pleural space into the drainage container. It also helps prevent backflow of fluid or air into the chest cavity, ensuring the effectiveness of the drainage system.
C. Empty the collection container every shift.
While it may be necessary to empty the collection container if it becomes full, emptying it every shift is not a set rule. The frequency of emptying the collection container should be based on the volume of drainage and the facility's policy. The nurse should monitor the collection container regularly and empty it when it reaches the appropriate level, typically around half full or as indicated by facility protocol.
D. Clamp the chest tubes if it becomes disconnected.
Clamping the chest tubes if they become disconnected is not recommended. It can lead to tension pneumothorax, a life-threatening condition where air accumulates in the pleural space and compresses the lung. If a chest tube becomes disconnected, the nurse should immediately assess the situation, secure the chest tube connections, and notify the healthcare provider for further management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Provide humidified oxygen.
Humidified oxygen adds moisture to the air, which can help to thin secretions in the airway. Thinning the secretions makes them easier to clear, particularly for patients with copious and tenacious secretions, such as those following a tracheostomy.
B. Perform chest physiotherapy prior to suctioning.
Chest physiotherapy techniques, such as percussion and vibration, can help to mobilize secretions in the lungs and airways. While this may indirectly assist in clearing secretions, it does not directly address the issue of thinning the secretions, which is the primary concern in this scenario.
C. Prelubricate the suction catheter tip with sterile saline when suctioning the airway.
Prelubricating the suction catheter tip with sterile saline before suctioning can help reduce friction and potential trauma to the airway. While this can be beneficial for airway management, it does not directly address the need to thin copious and tenacious secretions.
D. Hyperventilate the client with 100% oxygen before suctioning the airway.
Hyperventilating the client with 100% oxygen before suctioning is not recommended. It can lead to respiratory alkalosis, which is a condition characterized by decreased levels of carbon dioxide in the blood. This can worsen the client's condition and may lead to adverse effects. Additionally, it does not directly address the need to thin secretions.
Correct Answer is A
Explanation
A. 1 day after injection with a 10-mm area of redness and swelling:
This may suggest a positive reading, but induration size is the primary criterion for interpretation, not just redness and swelling.
B. 2 days after injection with a 5-mm area of redness and swelling:
Similar to option A, a 5-mm area of redness and swelling alone does not definitively indicate a positive TB skin test. Again, without information on the size of the induration, we cannot determine if this reading is positive.
C. 4 days after injection with a 3-mm area of redness and swelling:
Once more, a 3-mm area of redness and swelling alone does not definitively indicate a positive TB skin test. As with the previous options, the size of the induration is the critical factor for interpretation.
D. 5 days after injection with a 2-mm area of redness and swelling:
As with the other options, a 2-mm area of redness and swelling alone does not definitively indicate a positive TB skin test. The presence and size of induration are essential for accurate interpretation.
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