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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?

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 D

A. 1 cm of water present in the water seal chamber is within the expected range.

B. Tidaling with spontaneous respirations indicates the system is functioning properly.

C. Suction chamber pressure of -20 cm H2O is within the expected range for adequate suction.

D. The drainage collection chamber being one-third full suggests an accumulation of fluid beyond the expected level, which may indicate a potential complication such as hemorrhage or fluid buildup in the pleural space, requiring intervention by the nurse.

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Correct Answer is D,C,E,A,B

Explanation

D. Apply sterile gloves and place cleansing balls in antiseptic solution.

C. Lubricate the catheter and place fenestrated drape over perineum.

E. Cleanse the meatus with the dominant hand in a downward motion.

A. Insert the catheter until a flow of urine begins.

B. Attach prefilled syringe to indwelling catheter inflation hub.

A. Provide the client with a walker. B. Premedicate the client with the prescribed analgesic. C. Obtain the client's vital signs and oximetry prior to ambulation. D. Reinforce the client's surgical dressing.

Correct Answer is C

Explanation

A. Provide the client with a walker: While a walker may be used during ambulation, ensuring the client's physiological readiness for ambulation takes precedence.

B. Premedicate the client with the prescribed analgesic: While pain management is important for comfort during ambulation, premedication may not be necessary for all clients and should be based on individual assessment.

C. Obtain the client's vital signs and oximetry prior to ambulation: This intervention allows the nurse to assess the client's physiological status and ensure stability before initiating ambulation, reducing the risk of complications.

D. Reinforce the client's surgical dressing: While maintaining the integrity of the surgical

incision is important, reinforcing the dressing alone does not ensure the client's readiness for ambulation.

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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?

Nursing Test Bank

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