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D clamp thechest tubes ans a b c the nurse should

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d.Clamp thechest tubes.ANS: A, B, CThe nurse should prepare thepatient for chest tube removal by (1) assessing theneed forpre-removal analgesia and obtaining therequired medication orders, and (2) instructingthepatient about theprocess and what will be requested of thepatient. During removal ofthechest tube, it is important to instruct thepatient to take a deep breath and hold it untilthetube is removed. This maneuver prevents air from being sucked into thechest as thetube ispulled out and an occlusive dressing is applied. Although clamping of thechest tubes is doneto determine whether thechest tube can be eliminated, this is not part of theimmediate chesttube removal procedure.DIF:CognitiveLevel: ApplicationOBJ:Discuss thenursing principles involved in caring for patients with chest tubes.TOP: Chest Tube RemovalKEY: NursingProcess Step: ImplementationMSC: NCLEX: Physiological Integrity5.The nurse is caring for a patient who has a chest tube. Attached to thetop of thepatient‘s bedare two shodded hemostats. In which situations would these be used? (Select all that apply.)a.To assess an air leakb.To quickly empty or change disposable systemsc.To quickly seal off thelungs if thesystem becomes disconnectedd.To assess whether thepatient is ready to have thechest tube removedANS: A, B, DChest tubes are clamped only under thefollowing specific circumstances, per health careprovider order or nursing policy and procedure to assess air leak, to quickly empty or changedisposable systems, or to assess whether thepatient is ready to have thechest tube removed(which is done by a health care provider‘s order). Clamping an open system could lead to atension pneumothorax.DIF:CognitiveLevel: ApplicationStuvia.com - The Marketplace to Buy and Sell your Study MaterialDownloaded by: NurseProfessor | [email protected]Distribution of this document is illegalWant to earn$103 per month?
Stuvia.com - The Marketplace to Buy and Sell your Study MaterialOBJ:Describe methods of troubleshooting chest tube systems.TOP:Two-Chamber Waterless Chest Tube SystemKEY: NursingProcess Step: ImplementationMSC: NCLEX: Physiological Integrity6.The nurse is performing an initial assessment of a patient with a chest tube placed in theeighthintercostal space. Which of thefollowing findings would thenurse need to assess further?(Select all that apply.)a.Respiratory rate of 18 breaths per minuteb.Continuous bubbling in thewater-seal chamberc.The presence of subcutaneous emphysemad.Complaints of pain at theinsertion sitee.Serous drainage on thechest tube dressing thesize of a beanANS: B, C, DContinuous bubbling in thewater-seal chamber could indicate a leak in thesystem and shouldbe assessed further. thepresence of subcutaneous emphysema must be assessed furtherbecause it can be caused by a poor seal at thechest tube insertion site. Complaints of pain attheinsertion site can be expected but should be fully assessed before analgesics areadministered. A respiratory rate of 18 breaths per minute falls within thenormal range anddoes not, by itself, indicate a need for further assessment. A small amount of drainage onthechest tube dressing can be expected and serous drainage would be normal; however, itshould be monitored for any change in appearance.

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Term
Spring
Professor
MohsenMakhsous
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