A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?
Crepitus in the area above and surrounding the insertion site
Bubbling of the water in the water seal chamber with exhalation
Eyelets are not visible
Movement of the trachea toward the unaffected side
The Correct Answer is D
Choice A Reason: This is incorrect because crepitus in the area above and surrounding the insertion site is not a serious finding that requires notification of the provider. Crepitus is a crackling sensation that occurs when air leaks into the subcutaneous tissue. It is usually harmless and resolves on its own.
Choice B reason: This is incorrect because bubbling of the water in the water seal chamber with exhalation is a normal finding that indicates that air is being removed from the pleural space. Bubbling should stop when the pneumothorax is resolved.
Choice C Reason: This is incorrect because eyelets are not visible is not a serious finding that requires notification of the provider. Eyelets are small holes at the end of the chest tube that allow air and fluid to drain from the pleural space. They are usually covered by a dressing and may not be visible.
Choice D Reason: This is correct because movement of the trachea toward the unaffected side is a serious finding that indicates a tension pneumothorax, which is a life-threatening condition that occurs when air accumulates in the pleural space and causes pressure on the mediastinum. The nurse should notify the provider immediately and prepare for needle decompression or chest tube insertion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: Albumin 25% is not a medication that the nurse should plan to administer for a client who is experiencing Cushing's triad following a subdural hematoma. Albumin 25% is a colloid solution that increases the oncotic pressure and draws fluid from the interstitial space into the intravascular space, which can worsen the intracranial pressure by increasing the cerebral blood flow and edema.
Choice B Reason: Dextran 70 is not a medication that the nurse should plan to administer for a client who is experiencing Cushing's triad following a subdural hematoma. Dextran 70 is a plasma expander that increases the blood volume and viscosity, which can also worsen the intracranial pressure by increasing the cerebral blood flow and edema.
Choice C Reason: Mannitol 25% is a medication that the nurse should plan to administer for a client who is experiencing Cushing's triad following a subdural hematoma. Mannitol 25% is an osmotic diuretic that reduces the intracranial pressure by creating an osmotic gradient and drawing fluid from the brain tissue into the blood vessels, which can then be excreted by the kidneys. The nurse should monitor the urine output, serum osmolality, and electrolytes when administering mannitol 25%.
Choice D Reason: Hydroxyethyl starch is not a medication that the nurse should plan to administer for a client who is experiencing Cushing's triad following a subdural hematoma. Hydroxyethyl starch is another plasma expander that has similar effects as dextran 70, and can also increase the risk of coagulopathy and renal failure.
Correct Answer is A
Explanation
Choice A Reason: This is correct because dopamine is a vasopressor that increases the contractility and stroke volume of the heart, which results in an increased systolic blood pressure.
Choice B Reason: This is incorrect because dopamine can cause tachycardia as a side effect, but this does not indicate a therapeutic effect. An increased radial heart rate can also indicate other conditions, such as anxiety, fever, or dehydration.
Choice C Reason: This is incorrect because dopamine does not reduce cardiac output, but rather increases it by improving the pumping function of the heart.
Choice D Reason: This is incorrect because dopamine does not reduce urine output, but rather increases it by stimulating the renal blood vessels and enhancing renal perfusion.
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