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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The provider is not required to notify the client's employer about the admission to a mental health facility. This information is protected under confidentiality laws and regulations.
B. While the client may be strongly encouraged to take prescribed medications, they cannot be forced to do so without consent, especially if they are competent to make their own decisions.
C. Electroconvulsive therapy (ECT) typically requires informed consent from the patient or their legal representative, even in an involuntary admission scenario. Therefore, it is incorrect to state that ECT can be performed without consent.
D. If the client poses a risk of harm to themselves or others, the provider can prescribe restraints as a safety measure. This statement is correct and aligns with safety protocols in mental health facilities.
Correct Answer is A
Explanation
A.
A. Using a cell phone on the ear opposite to the pacemaker helps minimize the risk of electromagnetic interference with the pacemaker function.
B. Engaging in activities such as playing softball may not be appropriate immediately after pacemaker insertion. The client should follow specific activity restrictions as advised by the healthcare provider.
C. While performing arm exercises is generally beneficial for overall health, the client should avoid strenuous activities that may strain the upper body or disrupt the pacemaker leads
immediately after insertion.
D. Pacemaker battery replacement is typically scheduled based on the device's longevity and is performed in a healthcare facility, not the cardiologist's office. The client should follow up regularly with the healthcare provider for device checks and monitoring of battery status.
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