Nokea
The nurse is planning care for a client with a chest tube attached to a chest drainage system. Which actions should the nurse include as part of routine chest tube care? Select all that apply.
- A. Encourage the client to cough and deep breathe.
- B. Add water to the suction chamber as it evaporates.
- C. Keep the collection chamber below the client's waist.
- D. Clamp the chest tube when the client gets out of bed.
- E. Tape the connection between the chest tube and the drainage system.
Correct Answer: A,B,C,E
Rationale: The client is encouraged to cough and deep breathe to assist in lung expansion. Water is added to the suction control chamber as needed to maintain the full suction level prescribed. The nurse keeps the drainage collection system below the level of the client's waist to prevent fluid or air from reentering the pleural space. Connections between the chest tube and system are taped to prevent accidental disconnection. To avoid causing tension pneumothorax, the nurse avoids clamping the chest tube for any reason unless specifically prescribed. In most instances, clamping of the chest tube is contraindicated by agency policy.
You may also like to solve these questions
The nurse is caring for a client with a history of deep vein thrombosis (DVT) who is receiving heparin. The nurse should monitor the client for which of the following laboratory values?
- A. Activated partial thromboplastin time (aPTT).
- B. Prothrombin time (PT).
- C. International normalized ratio (INR).
- D. Platelet count.
Correct Answer: A, D
Rationale: Heparin is monitored with aPTT for therapeutic effect and platelet count for heparin-induced thrombocytopenia.
A client with a history of type 2 diabetes mellitus is prescribed pioglitazone (Actos). The nurse should monitor the client for which of the following side effects?
- A. Hypoglycemia.
- B. Weight gain.
- C. Hypertension.
- D. Dry skin.
Correct Answer: B
Rationale: Pioglitazone can cause weight gain due to fluid retention, requiring monitoring in diabetic clients.
When infusing total parenteral nutrition (TPN), the nurse should assess the client for which of the following complications?
- A. Essential amino acid deficiency.
- B. Essential fatty acid deficiency.
- C. Hyperglycemia.
- D. Infection.
Correct Answer: C,D
Rationale: TPN can cause hyperglycemia due to high glucose content and infection due to catheter use, both requiring vigilant monitoring.
Which of the following demonstrates that the client needs further instruction after being taught about ciprofloxacin (Cipro)?
- A. I must drink 1,000 to 1,500mL of water a day
- B. I shouldn't take an antacid before taking the Cipro
- C. I should let the doctor know if I start vomiting from the Cipro
- D. I may get light-headed from the Cipro
Correct Answer: A
Rationale: Adequate hydration is important with ciprofloxacin, but 1,000–1,500 mL may be insufficient for adults, who typically need 2,000–3,000 mL daily to prevent crystalluria. Other statements are correct.
A client with a diagnosis of systemic lupus erythematosus (SLE) is prescribed hydroxychloroquine (Plaquenil). The nurse should monitor the client for which of the following side effects?
- A. Weight gain.
- B. Retinal toxicity.
- C. Hypoglycemia.
- D. Hair loss.
Correct Answer: B
Rationale: Hydroxychloroquine can cause retinal toxicity, requiring regular eye exams to monitor for vision changes.