A nurse caring for a patient with a chest tube notices a sudden decrease in drainage with pink frothy sputum and crackles on auscultation. What condition should the nurse suspect, and what intervention is appropriate?

Tension pneumothorax; prepare for chest tube insertion on the affected side.

Subcutaneous emphysema; monitor respiratory status and elevate the head of the bed.

Re-expansion pulmonary edema; administer diuretics as ordered.

Infection; notify the physician and obtain cultures from the chest tube site.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The nurse should suspect tension pneumothorax in the patient with a chest tube who shows sudden decreased drainage, pink frothy sputum, and crackles on auscultation. Tension pneumothorax is a life-threatening condition where air accumulates in the pleural space, leading to increased pressure on the affected lung and heart. Immediate intervention, such as chest tube insertion on the affected side, is crucial to relieve the pressure and improve ventilation.

Choice B rationale:

Subcutaneous emphysema does not present with decreased drainage or pink frothy sputum. It is characterized by air trapped under the skin, causing a crackling sensation on palpation. Monitoring respiratory status and elevating the head of the bed are appropriate interventions for subcutaneous emphysema but not in this scenario.

Choice C rationale:

Re-expansion pulmonary edema is a rare complication that occurs after rapid lung re-expansion. It does not typically manifest with pink frothy sputum and crackles. Administering diuretics may be appropriate, but it is not the primary intervention in this situation.

Choice D rationale:

Infection does not explain the sudden decrease in drainage and pink frothy sputum. Although obtaining cultures from the chest tube site is important to assess for infection, it is not the most appropriate intervention at this moment. The priority is to address the potential tension pneumothorax.

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Correct Answer is ["B","D"]

Explanation

Choice A rationale:

Whole grains are generally recommended for individuals with diabetes as they provide a steady source of energy and contain fiber, which can help manage blood sugar levels.

Choice B rationale:

Fruits should be limited because they contain natural sugars, which can raise blood sugar levels. While fruits are a healthy choice, it's essential for people with diabetes to monitor their intake and choose lower-sugar options.

Choice C rationale:

Green leafy vegetables are generally encouraged for individuals with diabetes as they are low in calories and carbohydrates and have a positive impact on blood sugar levels.

Choice D rationale:

Saturated fats should be limited because they can contribute to insulin resistance and increase the risk of heart disease, which is already elevated in people with diabetes.

Choice E rationale:

Lean protein is a good choice for individuals with diabetes as it can help stabilize blood sugar levels and promote satiety without contributing to significant fluctuations in glucose.

A. "This is a normal finding and does not require any intervention.". B. "Let me clamp the tubing to see if the bubbling stops.". C. "I'll apply an occlusive dressing to seal the wound site.". D. "Notify the physician immediately; there might be an air leak.".

Correct Answer is D

Explanation

Choice A rationale:

Stating that continuous bubbling in the water-seal chamber is a normal finding and does not require any intervention is incorrect. Continuous bubbling indicates an air leak, and it requires prompt evaluation and intervention.

Choice B rationale:

Clamping the tubing to see if the bubbling stops is incorrect. Clamping the tubing would only be done to assess if the air leak is from the patient or the system, but it does not address the underlying issue.

Choice C rationale:

Applying an occlusive dressing to seal the wound site is incorrect. While dressing changes may be necessary to maintain a sterile environment, it will not resolve the air leak causing continuous bubbling.

Choice D rationale:

Notifying the physician immediately about the air leak is the appropriate nursing action. Continuous bubbling in the water-seal chamber suggests an air leak, which could compromise the effectiveness of the chest tube and require immediate medical attention.

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A nurse caring for a patient with a chest tube notices a sudden decrease in drainage with pink frothy sputum and crackles on auscultation. What condition should the nurse suspect, and what intervention is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with diabetes asks the nurse about dietary recommendations. The nurse should advise the client to limit the intake of which of the following foods? Select all that apply:

Correct Answer is ["B","D"]

Explanation

A nurse is caring for a patient with a chest tube and drainage system. The patient reports continuous bubbling in the water-seal chamber. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

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A nurse caring for a patient with a chest tube notices a sudden decrease in drainage with pink frothy sputum and crackles on auscultation. What condition should the nurse suspect, and what intervention is appropriate?

A nurse is preparing a patient for chest tube insertion. Which of the following nursing actions should the nurse take during the preparation process?

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