A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?

1 cm of water present in the water seal chamber

Tidaling with spontaneous respirations

Suction chamber pressure of -20 cm H20

Drainage collection chamber is one-third full

Answer and Explanation

The Correct Answer is A

A. The water seal chamber should contain at least 2 cm of water to maintain the seal and prevent air from entering the pleural space. Only 1 cm of water is inadequate and requires intervention.
B. Tidaling, or fluctuation of water with respirations, is an expected finding and indicates that the system is functioning properly.
C. A suction chamber pressure of -20 cm H₂O is the standard setting for chest tube drainage systems and does not require intervention.
D. A drainage collection chamber that is one-third full is within normal limits and simply indicates the need to continue monitoring output.

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Correct Answer is D

Explanation

A. Allergies to eggs are not typically a contraindication for a thyroid scan.

B. Latex allergies are not typically a contraindication for a thyroid scan unless latex-containing materials are involved in the procedure, such as gloves or adhesive bandages.

C. Allergies to peanuts are not typically a contraindication for a thyroid scan.

D. Iodine is the main component of the radioactive tracer used in a thyroid scan. If the client has a known allergy to iodine, it would be unsafe for them to undergo the scan.

A. Insist the client use direct eye contact during the interview. B. Seat the client at least 3.7 m (12 feet) from the nurse. C. Position the client's chair between the nurse's chair and the door. D. Lean in slightly when speaking to the client.

Correct Answer is D

Explanation

A. Insisting on direct eye contact may be uncomfortable or distressing for some clients, particularly those with certain mental health conditions or cultural backgrounds. It's important to respect the client's comfort level.

B. Seating the client too far away can create a sense of distance and may hinder effective communication. A closer seating arrangement facilitates rapport and engagement.

C. Positioning the client's chair between the nurse's chair and the door may make the client feel trapped or uncomfortable, especially if they have concerns about their safety or autonomy.

D. Leaning in slightly when speaking to the client demonstrates attentiveness and engagement. It can also convey a sense of confidentiality and respect for the client's space.

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A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?

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