A nurse is caring for a client following an insertion of a chest tube drainage system for a pneumothorax. Which of the following manifestations should the nurse expect the client to demonstrate?
Gentle bubbling in the water seal chamber
Drainage and warmth at tube insertion site
Crackling sensation felt around tube insertion site
Drainage output less than 70 mL/hr
The Correct Answer is A
A. Bubbling indicates that the system is functioning properly and that air is being evacuated from the pleural space.
B. Drainage and warmth at the tube insertion site could indicate inflammation or infection, which are potential complications following insertion of a chest tube.
C. Crackling sensation felt around tube insertion site could indicate subcutaneous emphysema, which occurs when air leaks into the tissues surrounding the chest tube insertion site. It's a potential complication of chest tube insertion and should be monitored closely
D. The specific amount can vary.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
B. Monitoring serum blood glucose during infusion is important because TPN can contain glucose, which may affect the client's blood glucose levels. Regular monitoring helps ensure glycemic control and prevents complications such as hyperglycemia.
C. Double-checking the TPN solution with another RN is a crucial safety measure to prevent medication errors and ensure that the correct solution is administered to the client.
E. Monitoring the client's weight daily is important for assessing fluid balance and adjusting the TPN infusion rate accordingly. Changes in weight can indicate fluid retention or loss, which may require adjustments to the TPN prescription.
A. TPN solutions must be administered according to the prescribed rate and schedule. Increasing the infusion rate without medical orders could lead to complications such as hyperglycemia or fluid overload.
D. TPN solutions are specifically formulated to meet the client's nutritional needs and cannot be substituted with other intravenous solutions like 0.9% sodium chloride.
Correct Answer is A
Explanation
A. Turning the client on their side helps prevent aspiration (inhaling fluid or vomit into the lungs) and promotes drainage of oral secretions, reducing the risk of airway obstruction during the seizure.
B. While assessing neurological status is important, it should be done after ensuring the client's safety during the seizure. This can be done after the seizure has stopped.
C. While obtaining vital signs is important for assessing the client's overall condition, it is not the immediate priority during an active seizure. Vital signs can be assessed once the seizure has stopped and the client's safety has been ensured.
D. Notifying the rapid response team may be necessary if the seizure persists beyond a certain duration (status epilepticus) or if there are complications. However, the first action should be to ensure the client's immediate safety by turning them onto their side to prevent aspiration.
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