PN Adult Medical Surgical 2020 - Exam 2
PN Adult Medical Surgical 2020 - Exam 2 ( 91 Questions)
Replacing the unit when the drainage chamber is full is not an appropriate action, as it can disrupt the negative pressure and cause air leaks or infection. The nurse should empty the drainage chamber when it is half-full and record the amount.
Pinning the tubing to the client's bed sheets is not an appropriate action, as it can cause kinks or occlusions in the tubing and impair drainage. The nurse should secure the tubing to the client's gown or chest wall with tape.
Monitoring for at least 150 mL of drainage every hour is an appropriate action, as it can indicate excessive bleeding or fluid accumulation in the pleural space. The nurse should report any sudden increase or decrease in drainage to the provider.
Clamping the tube for 30 min every 8 hr is not an appropriate action, as it can cause tension pneumothorax or fluid retention in the pleural space. The nurse should only clamp the tube briefly when changing the dressing or checking for air leaks.
Choice A reason: Replacing the unit when the drainage chamber is full is not an appropriate action, as it can disrupt the negative pressure and cause air leaks or infection. The nurse should empty the drainage chamber when it is half-full and record the amount.
Choice B reason: Pinning the tubing to the client's bed sheets is not an appropriate action, as it can cause kinks or occlusions in the tubing and impair drainage. The nurse should secure the tubing to the client's gown or chest wall with tape.
Choice C reason: Monitoring for at least 150 mL of drainage every hour is an appropriate action, as it can indicate excessive bleeding or fluid accumulation in the pleural space. The nurse should report any sudden increase or decrease in drainage to the provider.
Choice D reason: Clamping the tube for 30 min every 8 hr is not an appropriate action, as it can cause tension pneumothorax or fluid retention in the pleural space. The nurse should only clamp the tube briefly when changing the dressing or checking for air leaks.