A nurse is assessing a client who has a chest tube in place. Which of the following findings should the nurse report to the provider immediately?

Tidaling in the water seal chamber

Continuous bubbling in the water seal chamber

Drainage of 50 mL in the collection chamber over 8 hours

Chest tube secured with tape

Answer and Explanation

The Correct Answer is B

Choice A reason: Tidaling in the water seal chamber is normal, reflecting pleural pressure changes with breathing. It indicates a patent system, not requiring immediate reporting, making this incorrect.

Choice B reason: Continuous bubbling in the water seal chamber indicates an air leak, possibly from a system breach or lung injury. This requires immediate reporting to prevent pneumothorax, making it the correct choice.

Choice C reason: Drainage of 50 mL over 8 hours is within normal limits for a chest tube, not indicating hemorrhage. It requires monitoring but not immediate reporting, making this incorrect.

Choice D reason: A secured chest tube is expected and indicates proper maintenance. It does not warrant reporting, as it reflects standard care, making this incorrect for immediate concern.

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Correct Answer is B

Explanation

Choice A reason: Ambulation every 4 hours prevents complications like thrombosis but does not directly relieve incisional pain. Analgesics address pain immediately, making ambulation a secondary intervention.

Choice B reason: Administering a prescribed analgesic directly relieves incisional pain, improving comfort and recovery. Pain management is a priority post-cholecystectomy, making this the correct action for the nurse to take.

Choice C reason: A warm compress may increase bleeding or swelling at the incision site. Analgesics are safer and more effective for pain relief, making this an incorrect for postoperative care.

Choice D reason: Avoiding deep breathing risks infection, a postoperative complication. Analgesics relieve pain, enabling deep breathing to promote lung expansion, making this incorrect and counterproductive.

A. pH 7.35, PaCO2 40 mm Hg, HCO3- 25 mEq/L B. pH 7.4, PaCO2 35 mm Hg, HCO3- 35 mEq/L C. pH 7.3, PaCO2 36 mm Hg, HCO3- 19 mEq/L D. pH 7.45, PaCO2 45 mm Hg, HCO3- 30 mEq/L

Correct Answer is C

Explanation

Choice A reason: pH 7.35, PaCO2 40 mm Hg, HCO3- 25 mEq/L are normal values, indicating no acidosis. Metabolic acidosis involves low pH and low bicarbonate, which this does not show, making it incorrect.

Choice B reason: pH 7.4 is normal, and HCO3- 35 mEq/L suggests metabolic alkalosis, not acidosis. Renal failure and diabetes typically cause acidosis due to acid accumulation, making this inconsistent with metabolic acidosis.

Choice C reason: pH 7.3 (low) and HCO3- 19 mEq/L (low) with normal PaCO2 indicate metabolic acidosis, common in renal failure due to impaired acid excretion and diabetic ketoacidosis, making this the correct choice.

Choice D reason: pH 7.45 and HCO3- 30 mEq/L suggest metabolic alkalosis, not acidosis. Elevated bicarbonate is opposite to the low levels expected in metabolic acidosis, making this incorrect for the patient’s condition.

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A nurse is assessing a client who has a chest tube in place. Which of the following findings should the nurse report to the provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following a cholecystectomy and reports incisional pain. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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