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 B

Explanation

Choice A: Sweaty palms may be related to various factors, including anxiety, physical activity, or environmental conditions. While it may warrant further assessment, it is not necessarily indicative of a nutritional issue in a professional dancer.

Choice B: Fatigue in a professional dancer can be a concerning issue and may indicate an underlying nutritional problem, such as inadequate calorie intake or nutrient deficiencies. Further assessment of the client's dietary habits and energy levels is warranted.

Choice C: Bunions are a foot deformity and are not directly related to nutritional assessment.

Choice D: Dry skin may be related to various factors, including environmental conditions and skin care practices. It may warrant assessment but is not necessarily indicative of a nutritional issue.

A. Broccoli. B. Milk shake. C. Garden salad. D. Coffee.

Correct Answer is B

Explanation

Choice A: Broccoli is not typically restricted before a gallbladder ultrasound.

Choice B: Instructing the client to avoid consuming a milkshake the night before the test is important because a fatty meal can affect gallbladder contraction and visualization during the ultrasound.

Choice C: A garden salad is not typically restricted before a gallbladder ultrasound.

Choice D: Coffee is not typically restricted before a gallbladder ultrasound.

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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

The nurse is performing a nutritional assessment on a client who is professional dancer. Which issue reported by the client should alert the nurse to perform further assessment?

Correct Answer is B

Explanation

The nurse is preparing a client for ultrasonography of the gallbladder. What should the nurse instruct the client to avoid consuming the night before the test?

Correct Answer is B

Explanation

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