Ati lpn level 3 med surg resp test
Ati lpn level 3 med surg resp test ( 14 Questions)
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?
Maintain the drainage container below the level of the client's chest. Keeping the drainage container below the level of the client's chest allows gravity to assist in draining fluid or air from the pleural space and prevents backflow into the chest.
Add tap water as needed to the suction control chamber: This is incorrect; sterile water should be used, not tap water, to prevent contamination.
Clamp the chest tubes if it becomes disconnected: This is not recommended as clamping can create a tension pneumothorax. Instead, the nurse should use a sterile gauze to cover the site and notify the provider.
Empty the collection container every shift: The collection container should be emptied as needed, not on a set schedule, to ensure proper function and accurate measurement of drainage.
A. Maintain the drainage container below the level of the client's chest. Keeping the drainage container below the level of the client's chest allows gravity to assist in draining fluid or air from the pleural space and prevents backflow into the chest.
B. Add tap water as needed to the suction control chamber: This is incorrect; sterile water should be used, not tap water, to prevent contamination.
C. Clamp the chest tubes if it becomes disconnected: This is not recommended as clamping can create a tension pneumothorax. Instead, the nurse should use a sterile gauze to cover the site and notify the provider.
D. Empty the collection container every shift: The collection container should be emptied as needed, not on a set schedule, to ensure proper function and accurate measurement of drainage.