The nurse is caring for a client with a chest tube. Which is the following statements is appropriate regarding a chest tube?
The chest tube drainage system should be placed on the bedside table.
The chest tube drainage system should be placed on the bed near the patient.
The chest tube drainage system must be placed below the site of insertion.
The chest tube drainage system should be placed on the siderail near the patient.
The Correct Answer is C
: Chest tube placement is done to remove air or fluid from the pleural space, which is the area between the lungs and the chest wall. The chest tube drainage system is an important tool to monitor and manage the drainage from the chest tube.
It is essential that the chest tube drainage system is placed below the level of the patient's chest and the site of insertion. This is necessary to create a continuous drainage system by allowing gravity to assist in the flow of air or fluid out of the pleural space. If the chest tube drainage system is placed above the insertion site, the fluid will not drain properly, which can cause the fluid to back up into the patient's chest cavity, leading to complications such as pneumothorax or hemothorax.
Therefore, the appropriate statement regarding a chest tube is that the chest tube drainage system must be placed below the site of insertion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Hypertonic solutions have a higher concentration of solutes (such as sodium, glucose, or mannitol) than the fluid in the body's cells, causing water to move out of the cells and into the bloodstream. This results in the shrinking of the cells and an increase in extracellular fluid volume.
Examples of hypertonic solutions include 10% dextrose in water (D10W), 3% saline, and 5% dextrose in 0.9% saline.
In contrast, isotonic solutions have the same concentration of solutes as the fluid in the body's cells, and hypotonic solutions have a lower concentration of solutes than the fluid in the body's cells.
Therefore, in this scenario, the nurse should administer a hypertonic solution to the client who requires IV fluids.
Correct Answer is D
Explanation
Explanation: In clients with COPD, the secretions tend to be thick and sticky, which makes it difficult to cough up and clear the airway. To promote respiratory hygiene in this situation, the nurse should recommend increasing fluid intake. Adequate hydration helps to thin the secretions, making them easier to expectorate. The client should aim to drink at least 8-10 glasses of water or other fluids per day unless there is a medical reason not to do so.
Decreasing fluid intake (option a) would make the secretions even thicker and more difficult to clear. Taking Tylenol for secretions (option b) is not a recommended intervention as Tylenol is not indicated for thinning of secretions. Range-of-motion exercises (option c) are important to prevent complications such as pneumonia, but they are not directly related to promoting respiratory hygiene in this situation.
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