Question

A nurse is caring for a client who had an open thoracotomy with chest tube insertion. Which of the following actions should the nurse take?

A) Clamping the chest tube during ambulation.
B) Encouraging shallow breathing to minimize pain.
C) Monitoring the drainage system for air leaks.
D) Administering anticoagulants to prevent clot formation.

Answer 1

The nurse should monitor the drainage system for air leaks when caring for a patient with a chest tube after thoracotomy to ensure proper recovery and to avoid complications such as a tension pneumothorax. (option c)

Step-by-step explanation:

The correct action a nurse should take when caring for a client who had an open thoracotomy with chest tube insertion is C) Monitoring the drainage system for air leaks. This is crucial as air leaks can signal a disconnection or issue with the chest tube system which could compromise the patient's recovery.

Clamping the chest tube during ambulation (A) is generally not advised as this can increase the risk of tension pneumothorax. Encouraging shallow breathing (B) is not advisable either because deep breathing is important to help clear the lungs and prevent pneumonia.

Administering anticoagulants (D) is not typically related to the care of a chest tube unless the patient has an established need for anticoagulation for another medical reason.

Hence, the answer is option c