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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Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"B"}}
Explanation
The client's record indicate that they are experiencing a myocardial infarction due to the elevated markers of inflammation, cardiac biomarkers and typical ECG findings.
Management of myocardial infarction includes oxygen supplementation, nitroglycerin, morphine sulphate, beta blocker such as metoprolol and aspirin/clopidogrel
Among the triggers of myocardial infarction can be cardiac dysrhythmias. This can be caused by electrolytes disturbances and hence the need to draw electrolytes.
Correct Answer is B
Explanation
B. Sublingual nitroglycerin is intended for the immediate relief of angina symptoms. Clients should take the medication as soon as they experience chest pain or discomfort. Prompt administration can help alleviate symptoms and prevent the progression of angina episodes.
A. If the chest pain persists or worsens after taking the first dose of sublingual nitroglycerin, the client can take a second dose after 5 minutes. However, taking another dose after only 2 minutes may increase the risk of hypotension and other adverse effects.
C. Sublingual nitroglycerin tablets are not meant to be chewed or swallowed. Instead, they should be placed under the tongue and allowed to dissolve completely. Chewing or swallowing the tablet can reduce the medication's effectiveness.
D. Sublingual nitroglycerin should be placed under the tongue, not against the cheek or gum.
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