A nurse is assessing a client who is 1 day postoperative following a lobectomy and has a chest tube drainage system in place. Which of the following findings by the nurse indicates a need for intervention?

Development of subcutaneous emphysema

Chest tube eyelets not visible

Continuous bubbling in the suction control chamber

Presence of tidal fluctuation in the water seal chamber

Answer and Explanation

The Correct Answer is A

The correct answer is: a. Development of subcutaneous emphysema

Choice A: Development of subcutaneous emphysema

Reason: Subcutaneous emphysema occurs when air gets trapped under the skin, often due to a leak from the lung or chest tube. This can indicate a serious complication such as a pneumothorax or a malfunctioning chest tube, requiring immediate medical intervention. The presence of subcutaneous emphysema can lead to discomfort, respiratory distress, and further complications if not addressed promptly.

Choice B: Chest tube eyelets not visible

Reason: The eyelets of a chest tube are small holes at the end of the tube that allow air and fluid to drain from the pleural space. These eyelets are typically covered by a dressing and may not be visible. This is not necessarily a cause for concern unless there are other signs of malfunction or complications.

Choice C: Continuous bubbling in the suction control chamber

Reason: Continuous bubbling in the suction control chamber is expected and indicates that the suction is functioning properly. It does not indicate a problem unless the bubbling is in the water seal chamber, which would suggest an air leak.

Choice D: Presence of tidal fluctuation in the water seal chamber

Reason: Tidal fluctuation, or tidaling, in the water seal chamber is a normal finding. It indicates that the chest tube is patent and functioning correctly, as the water level rises with inhalation and falls with exhalation. The absence of tidaling could indicate a blockage or that the lung has fully re-expanded.

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Correct Answer is A

Explanation

Choice A reason: Rinse the mouth after administration. This answer is correct because rinsing the mouth after using inhaled beclomethasone can help prevent oral candidiasis, a fungal infection that can cause soreness, white patches, and bleeding in the mouth.

Choice B reason: Check the pulse after medication administration. This answer is incorrect because checking the pulse after using inhaled beclomethasone is not necessary, as this medication does not affect the heart rate or blood pressure. Inhaled beclomethasone is a corticosteroid that reduces inflammation and swelling in the airways.

Choice C reason: Limit caffeine intake. This answer is incorrect because limiting caffeine intake is not related to the use of inhaled beclomethasone, but rather to the management of asthma symptoms. Caffeine can act as a bronchodilator and improve lung function, but it can also cause nervousness, insomnia, and palpitations in some people.

Choice D reason: Take the medication with meals. This answer is incorrect because taking the medication with meals is not relevant to the use of inhaled beclomethasone, as this medication is not taken orally but by inhalation. Inhaled beclomethasone is delivered directly to the lungs, where it exerts its anti-inflammatory effect.

A. The client exhales as the medication is released from the inhaler. B. The client waits 10 minutes between inhalations. C. The client holds his breath for 10 seconds after inhaling the medication. D. The client takes a quick inhalation while releasing the medication from the inhaler.

Correct Answer is C

Explanation

Choice A reason: The client exhales as the medication is released from the inhaler. This action is incorrect because it wastes the medication and reduces its effectiveness. The client should exhale before using the inhaler, not during.

Choice B reason: The client waits 10 minutes between inhalations. This action is incorrect because it delays the relief of the asthma symptoms. The client should wait only one minute between inhalations, unless instructed otherwise by the doctor.

Choice C reason: The client holds his breath for 10 seconds after inhaling the medication. This action is correct because it allows the medication to reach the lungs and bronchial tubes more effectively and reduce the inflammation and constriction of the airways.

Choice D reason: The client takes a quick inhalation while releasing the medication from the inhaler. This action is incorrect because it can cause the medication to hit the back of the throat and not reach the lungs. The client should take a slow and deep inhalation while using the inhaler.

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A nurse is assessing a client who is 1 day postoperative following a lobectomy and has a chest tube drainage system in place. Which of the following findings by the nurse indicates a need for intervention?

Nursing Test Bank

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