The unlicensed nursing assistant is assisting the client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention from the nurse?
- The client’s chest tube is below the level of the chest.
- The nursing assistant has the chest tube attached to suction.
- The nursing assistant allowed the client out of the bed.
- The nursing assistant uses a bedside commode for the client.
Post your answer in the comment section.
CORRECT ANSWER IS 2
2. The chest tube system can function as a result of gravity and does not have to be attached to suction. Keeping it attached to suction could cause the client to trip and fall. Therefore, this is a safety issue and the nurse should intervene and explain this to the nursing assistant.
1. Keeping the drainage system lower than the chest promotes drainage and prevents reflux.
3. Ambulation facilitates lung ventilation and expansion; drainage systems are portable to allow ambulation while chest tubes are in place.
4. The client should ambulate, but getting up and using the bedside commode is better than stay- ing in the bed, so no action would be needed.
TEST-TAKING HINT: “Warrants immediate intervention” means the test taker must identify the situation in which the nurse should intervene and correct the action, demonstrate a skill, or somehow intervene with the unlicensed assistant’s behavior.
2
2
Option 2
2
2
2
2
2
2
2
2
2
2
2
2