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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
Choice A reason: Hypotension is not a common manifestation of ARF. Hypotension is a low blood pressure, defined as less than 90/60 mm Hg. Hypotension can have many causes, such as dehydration, blood loss, heart problems, or medications. ARF does not directly cause hypotension, but it can lead to complications such as shock or organ failure, which can lower the blood pressure.
Choice B reason: Decreased level of consciousness is a frequent manifestation of ARF. Decreased level of consciousness is a state of impaired awareness, orientation, memory, or judgment. Decreased level of consciousness can occur in ARF due to several factors, such as hypoxia, hypercapnia, acidosis, or infection. The nurse should monitor the mental status of the client with ARF and report any changes to the provider.
Choice C reason: Severe dyspnea is a common manifestation of ARF. Dyspnea is a subjective sensation of difficulty breathing or shortness of breath. Severe dyspnea can occur in ARF due to the reduced oxygen delivery or increased carbon dioxide retention in the blood. The nurse should assess the respiratory rate, rhythm, depth, and effort of the client with ARF and provide oxygen therapy as prescribed.
Choice D reason: Headache is not a typical manifestation of ARF. Headache is a pain or discomfort in the head, scalp, or neck. Headache can have many causes, such as stress, dehydration, sinusitis, or migraine. ARF does not directly cause headache, but it can cause increased intracranial pressure or cerebral edema, which can trigger headache.
Choice E reason: Nausea is not a usual manifestation of ARF. Nausea is a feeling of sickness or discomfort in the stomach that can lead to vomiting. Nausea can have many causes, such as food poisoning, motion sickness, pregnancy, or medications. ARF does not directly cause nausea, but it can cause gastrointestinal bleeding or hepatic encephalopathy, which can induce nausea.
Correct Answer is B
Explanation
Choice A reason: "My wife tries to get me to go to the grocery store, but I don't like to go out much." This statement indicates that the client is not adapting well, as they are avoiding social activities and isolating themselves. The client may have low self-esteem, depression, or anxiety.
Choice B reason: "I am using the modified feeding utensils at every meal. I still spill, but I'm getting better." This statement indicates that the client is adapting well, as they are using adaptive devices and practicing their skills. The client also expresses a positive attitude and a sense of improvement.
Choice C reason: "My greatest pleasure each day is having a few beers every day." This statement indicates that the client is not adapting well, as they are abusing alcohol and possibly selfmedicating. The client may have emotional distress, chronic pain, or addiction.
Choice D reason: "I have all the equipment to take a shower, but I prefer a bed bath, because it is easier." This statement indicates that the client is not adapting well, as they are not using the available resources and opting for a less independent option. The client may have low motivation, poor selfcare, or learned helplessness.
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