The nurse caring for a client with a chest tube to water seal is ...

[lak]

The nurse caring for a client with a chest tube to water seal is bathing and changing the linen when the sealed drainage system becomes damaged and the client suddenly becomes short of breath. The nurse's priority action is to:
 
  1. Clamp the chest tube closer to the client.
  2. Have the client cough forcefully.
  3. Connect a new sealed drainage system.
  4. Notify the charge nurse and physician.

Question 2

The nurse chooses a wound V.A.C. for the following types of wounds: Standard Text: Select all that apply.
 
  1. A venous stasis leg ulcer
  2. Deep pressure ulcers
  3. Partial-thickness burns
  4. Wounds with large volume of drainage
  5. Wounds that need to be dry to heal

[Pariscourtney]

Answer to Question 1

1
Rationale: This is an emergency situation, because air now can enter the client's pleural cavity, so the immediate intervention by the nurse is to clamp the chest tube until a new sealed drainage system can be obtained and connected. Coughing forcefully will do nothing for the client. After clamping the chest tube, the nurse can call for help to obtain a new system while staying with the client, elevating the head of the bed, applying oxygen, and monitoring the client's condition. An incident report should be completed when the client is stabilized.

Answer to Question 2

2,3,4
Rationale: A venous stasis ulcer would be better treated with a hydrocolloid dressing that can be molded to uneven body surfaces.