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 D

Explanation

Choice A: The older female client who had a hip replacement yesterday and is notably pale with a hemoglobin of 10.5 g/dl likely needs attention, but the information provided does not indicate an urgent, life-threatening situation. Immediate intervention may not be necessary based on the information given.

Choice B: The adult client with osteomyelitis of the ankle who refuses an IV restart for antibiotics is concerning, but it does not represent an immediate life- threatening situation. The client's refusal should be addressed, but it may not require immediate attention.

Choice C: The elderly client with low back pain who removed pelvic traction and wants to go home may require assessment and intervention, but the information provided does not indicate an urgent, life-threatening situation. It may not be the first priority.

Choice D: The young adult client with a closed reduction of a fractured femur complaining of increasingly severe pain is the most concerning. Pain assessment and management are critical, and uncontrolled pain can lead to complications. This client should be attended to first to assess and address the pain.

A. Client receiving 30% oxygen via a non-rebreather face mask. B. Client with a nasogastric tube to low, intermittent suction. C. Client experiencing dysphagia who is prescribed a full liquid diet. D. Client who has sensory aphasia and is receiving a clear liquid diet.

Correct Answer is C

Explanation

Choice A: A client receiving 30% oxygen via a non-rebreather face mask may be at risk for oxygen toxicity, but it does not necessarily indicate a higher risk of aspiration.

Choice B: A client with a nasogastric tube to low, intermittent suction may be at risk for aspiration if the tube is not functioning properly, but it does not represent the greatest risk compared to the other options.

Choice C: A client experiencing dysphagia who is prescribed a full liquid diet is at the greatest risk for aspiration. Dysphagia can lead to difficulty swallowing, increasing the risk of food or liquids entering the airway during swallowing.

Choice D: A client who has sensory aphasia and is receiving a clear liquid diet may have difficulty understanding or communicating about their dietary needs, but this does not necessarily indicate a higher risk of aspiration compared to a client with dysphagia.

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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

After receiving morning report about four clients, which client should the nurse attend to first?

Correct Answer is D

Explanation

Which client is at greatest risk for aspiration?

Correct Answer is C

Explanation

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