Question

The nurse is caring for the client following the placement of a chest tube for a hemothorax.

Which of the following actions should the nurse take? Select all that apply.
a) Strip the drainage tubing to ensure it is patent.
b) Monitor drainage every 30 min for the first hour.
c) Ensure that all chest tube connections are securely attached.
d) Palpate the chest tube insertion site for subcutaneous emphysema.
e) Place the client in high-Fowler's position.

Answer 1

b) Monitor drainage every 30 min for the first hour.The nurse's responsibilities include monitoring drainage vigilantly, ensuring secure connections of the chest tube system,complications,

Step-by-step explanation:

The care of a client with a chest tube for a hemothorax includes several important steps. When answering which actions a nurse should take, it's essential to understand that:

• Stripping the drainage tubing, which was once a common practice, is now often discouraged because it can create excessive negative pressures that might damage tissue.
• Monitoring drainage every 30 min for the first hour is critical to assess for rapid blood loss and to ensure the chest tube is functioning properly.
• Ensuring that all chest tube connections are securely attached is vital to prevent disconnection and loss of negative pressure within the chest cavity.
• Palpating the chest tube insertion site for subcutaneous emphysema is important for detecting complications such as air escaping into the tissue.
• Positioning the client in high-Fowler's position can promote lung expansion and ease breathing unless contraindicated due to patient condition or specific orders.