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: Socioeconomics can influence a person's ability to access and afford certain foods, but the statement does not directly address the nutritional guidelines for older adults.

Choice B: Nutritional meal planning for seniors should ideally involve input from a dietitian or healthcare provider, but the statement does not directly reflect an understanding of the nutritional guidelines.

Choice C: Dietary needs for seniors over and under age 70 can differ due to factors such as changes in metabolism, physical activity levels, and overall health. The statement recognizes the importance of tailoring the meal plan to meet the specific nutritional needs of both spouses based on their respective ages.

Choice D: Age is a factor in determining dietary needs for seniors, as nutritional requirements may change as individuals age. The statement acknowledges that age plays a role in meal planning for older adults.

A. Permanent life-style changes need to be made to promote safety in the home. B. Muscle tension is decreased with fine motor skill projects, so these activities should be encouraged C. Consistent discipline is needed to help the child control the movements. D. The chorea or movements are temporary and will eventually disappear.

Correct Answer is D

Explanation

Choice A: Permanent lifestyle changes may not be necessary for a child with rheumatic fever and associated chorea. Rheumatic fever is typically treated with antibiotics to clear the streptococcal infection and prevent further complications.

Choice B: Muscle tension is not typically decreased with fine motor skill projects, and encouraging such activities may not directly address the symptoms of chorea. Fine motor activities can be pursued if they are enjoyable for the child but should not be presented as a primary treatment.

Choice C: Consistent discipline is important for children but may not be the primary focus when addressing chorea associated with rheumatic fever. Discipline should be appropriate and consistent but should not be the primary intervention for chorea.

Choice D: The chorea or movements are temporary and will eventually disappear. This is the most accurate and reassuring information to provide to the parents. Chorea associated with rheumatic fever typically resolves over time with appropriate treatment, and the child is expected to recover fully.

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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 helping develop a meal plan based on nutritional guidelines for a 73-year-old client being discharge to home with the client's 65- year-old spouse. Which statement best indicates an understanding of the nutritional guidelines when planning meals by the two spouses?

Correct Answer is C

Explanation

A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea (sudden aimless movements of the arms and legs). Which information should the nurse provide to the parents?

Correct Answer is D

Explanation

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