A nurse is caring for a client who has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?

Occasional bubbling in the water-seal chamber

No reports of pleuritic chest pain

No tidaling in the water-seal chamber

Oxygen saturation of 95%

Answer and Explanation

The Correct Answer is C

Choice A reason: Occasional bubbling in the water-seal chamber can indicate an air leak, which is not necessarily a sign of lung re-expansion. It could suggest that the lung has not fully re-expanded or that there is a persistent air leak.

Choice B reason: While the absence of pleuritic chest pain is a positive sign, it is not a definitive indicator of lung re-expansion. Pleuritic chest pain can subside even if the lung has not fully re-expanded.

Choice C reason: No tidaling in the water-seal chamber is a strong indicator that the lung has re-expanded. When the lung is fully expanded, it presses against the chest wall, eliminating the space where air could collect and thus stopping the water level from fluctuating with respiration.

Choice D reason: An oxygen saturation of 95% is within normal limits and suggests adequate oxygenation, but it does not specifically indicate lung re-expansion. Oxygen saturation can be maintained with supplemental oxygen or other supportive measures even if the lung has not fully re-expanded.

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Correct Answer is ["0.2"]

Explanation

- Step 1: Identify the required dose in milligrams (mg). The nurse is scheduled to administer 2 mg of morphine sulfate.

- Step 2: Identify the concentration of the available solution. The available solution contains 10 mg of morphine sulfate per 1 mL.

- Step 3: Calculate the volume of solution needed to deliver the required dose. We can set up a proportion to solve for this:

- 10 mg is to 1 mL as 2 mg is to X mL.

- In other words, 10 mg : 1 mL = 2 mg : X mL.

- Step 4: Solve for X using cross-multiplication and division:

- Cross-multiplication gives us: 10 mg × X mL = 2 mg × 1 mL.

- Simplifying this gives us: 10X = 2.

- Dividing both sides by 10 gives us: X = 2 ÷ 10.

- Calculating the division gives us: X = 0.2.

So, the nurse should administer 0.2 mL of the morphine sulfate solution per dose.

A. Tape the connections on the client's chest tube. B. Position the client in a supine position. C. Strip the client's chest tube every 2 hours. D. Place the chest tube drainage system above the level of the client's heart.

Correct Answer is A

Explanation

Choice A reason:Taping the connections on the client's chest tube is essential to maintain a closed system and prevent air leaks, which could lead to a pneumothorax.

Choice B reason:Positioning the client in a supine position is not recommended as it may not facilitate optimal drainage from the pleural space.

Choice C reason:Stripping the chest tube, which involves applying pressure and sliding the fingers down the tube to remove clots, is not routinely recommended as it can generate high negative pressures and damage lung tissue.

Choice D reason: The chest tube drainage system should be placed below the level of the client's heart to allow for gravity drainage of pleural fluid and air.

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A nurse is caring for a client who has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a 2 mg IV bolus of morphine sulfate. Morphine sulfate is available in a concentration of 10 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.2"]

Explanation

A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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