A client with a hemothorax has a chest tube in the fourth intercostal space connected to suction at 20 cm H2O pressure. Four hours after insertion, which client outcome should the nurse consider to be within normal limits for this client?

Fluctuation with respiration in the water-seal chamber of the

The dry gauze dressing over the insertion site is clean and intact.

No bubbling in the suction chamber of the Pleura.

Serous fluid in the drainage chamber of the Pleura.

Answer and Explanation

The Correct Answer is A

Choice A: Fluctuation with respiration in the water-seal chamber of the chest drainage system is a normal and expected finding for a client with a chest tube in place. It indicates that the system is functioning correctly and allows for the removal of air or fluid from the pleural space during inspiration and expiration.

Choice B: The condition of the dry gauze dressing over the insertion site is important for monitoring any potential signs of infection or bleeding but does not directly relate to the functioning of the chest tube.

Choice C: No bubbling in the suction chamber of the Pleur-Evac system may indicate that the suction pressure is not adequately transmitted to the chest tube or that there is an issue with the system's seal. This finding is not within normal limits and should be addressed.

Choice D: The presence of serous fluid in the drainage chamber of the Pleur- Evac system is expected and indicates that drainage from the pleural space is occurring. However, the key assessment for proper chest tube function is the fluctuation in the water-seal chamber with respiration.

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Correct Answer is C

Explanation

Choice A: Salad greens with tomatoes do not provide a significant source of protein.

Choice B: One slice of cheese pizza may contain saturated fats from cheese and processed meats, so it may not be the best choice if the goal is to reduce saturated fat intake.

Choice C: A roasted turkey sandwich can be a good alternative source of protein without the same level of saturated fats found in hamburgers. Turkey is typically leaner than beef, and if prepared without excessive fats or sauces, it can be a healthier choice.

Choice D: Baked potato with low-fat butter is primarily a source of carbohydrates and fats but does not provide a significant source of protein.

A. Hematocrit. B. Albumin and protein. C. White blood cell count (WBC). D. Electrolytes.

Correct Answer is D

Explanation

Choice A: Hematocrit is a measure of the proportion of blood volume occupied by red blood cells. While it can provide information about anemia or dehydration, it is not typically the first consideration in evaluating numbness and tingling in the extremities.

Choice B: Reviewing albumin and protein levels may be important for assessing overall nutritional status and potential causes of neuropathy but is not the immediate priority when a client reports numbness and tingling in the extremities.

Choice C: White blood cell count (WBC) is important for assessing immune function and the presence of infections. However, it is not typically the primary focus when evaluating numbness and tingling in the extremities.

Choice D: Electrolytes, such as serum sodium and potassium levels, are crucial to review when a client reports numbness and tingling in the extremities. Abnormal electrolyte levels can lead to neurological symptoms, and a review of electrolyte levels can help identify potential causes.

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A client with a hemothorax has a chest tube in the fourth intercostal space connected to suction at 20 cm H2O pressure. Four hours after insertion, which client outcome should the nurse consider to be within normal limits for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client expresses an interest in reducing intake of saturated fats and plans to stop eating hamburgers at lunch. Which menu item should the nurse suggest as an alternative source of protein?

Correct Answer is C

Explanation

A client reports feeling numbness and tingling in the extremities. Which of the client's serum laboratory values should the practical nurse (PN) review before reporting the finding?

Correct Answer is D

Explanation

When conducting diet teaching for a client who was diagnosed with hypocalcemia, which foods should the nurse encourage the client to eat? (Select all that apply.)

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