A nurse is caring for a client following the placement of a chest tube drainage system for a pneumothorax. Which of the following findings should the nurse expect?
Serous drainage noted in the collection chamber
Tidaling in the water seal chamber with respirations
Diminished breath sounds in the lung bases
Movement of the trachea toward the unaffected side
The Correct Answer is B
A. Serous drainage noted in the collection chamber: The type of drainage typically seen with a pneumothorax is not serous; it is usually minimal or absent. If there is significant drainage, it could indicate bleeding or another issue that should be monitored.
B. Tidaling in the water seal chamber with respirations: Tidaling, or the movement of the water level in the water seal chamber with respirations, is a normal finding. It indicates that the chest tube is correctly placed, and the lung is expanding and contracting.
C. Diminished breath sounds in the lung bases: Diminished breath sounds are expected in the area where the pneumothorax occurred, but it does not specifically indicate the placement of the chest tube.
D. Movement of the trachea toward the unaffected side: Tracheal deviation toward the unaffected side is a sign of tension pneumothorax, which is a medical emergency. It should not be expected following the placement of a chest tube for a pneumothorax, as the goal of the chest tube is to resolve the pneumothorax and prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Increased sexual desire: Menopause typically leads to a decrease in sexual desire due to the reduction in estrogen levels. This hormonal shift can cause physical changes such as vaginal dryness and discomfort, further impacting libido.
B. Decreased bone density: Estrogen plays a crucial role in maintaining bone density, and its decline during menopause accelerates bone resorption. This results in decreased bone mass and an increased risk of osteoporosis and fractures.
C. Decreased sweating: Hot flashes, characterized by sudden increases in body temperature followed by sweating, are a hallmark symptom of menopause. These occur due to changes in the hypothalamus's regulation of temperature, often triggered by fluctuating estrogen levels.
D. Increased vaginal secretions: As estrogen levels decrease during menopause, vaginal tissues become thinner and less lubricated. This often results in vaginal dryness and discomfort, which can cause pain during intercourse and increase the risk of infections.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
Rationale for correct choices:
- Infection: Clients with HIV are immunocompromised and already at increased risk for infections. A declining WBC count, especially falling below the normal range (4,100/mm³ from 4,500/mm³), indicates worsening immunosuppression, further elevating the infection risk.
- WBC count: White blood cells are crucial for immune defense. In HIV clients, a low or decreasing WBC count suggests progressing immunodeficiency, making the body less able to fight infections, especially opportunistic ones.
Rationale for incorrect choices:
- Dysrhythmias: The client's potassium level is 3.8 mEq/L, well within normal limits (3.5–5 mEq/L). There is no electrolyte imbalance that would predispose the client to cardiac rhythm disturbances.
- Renal failure: BUN is slightly elevated from 16 to 18 mg/dL, but still within the normal range (10–20 mg/dL). This mild change is not enough to suggest renal dysfunction or failure.
- Bleeding: Platelet count is stable and within normal limits at 162,000/mm³. Thrombocytopenia becomes more concerning at values below 150,000, so there is no immediate bleeding risk.
- Seizures: The sodium level is 139 mEq/L, which is within the normal range. There are no abnormal electrolyte findings or neurological symptoms to indicate seizure risk.
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