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%
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The GFR does not recover during the oliguric phase; instead, it is typically reduced, reflecting impaired kidney function.
Choice B reason: Urine output of less than 400 mL per 24 hours is characteristic of the oliguric phase of AKI. This phase can last from 1 to 7 days after kidney injury and is a crucial time for monitoring and managing the patient's fluid and electrolyte balance.
Choice C reason: BUN and creatinine levels do not decrease during the oliguric phase. They usually increase due to reduced kidney function and the inability to excrete these waste products.
Choice D reason: Renal function is not reestablished during the oliguric phase. This phase is part of the course of AKI where renal function is at its lowest, and recovery has not yet begun.
Correct Answer is D
Explanation
Choice A. An embolic stroke is caused by an embolus, often a blood clot, that travels to the brain from another part of the body. It does not typically present with a sudden, severe headache.
Choice B. A thrombotic stroke occurs when a blood clot forms inside one of the brain's arteries. While it can cause a headache, it is not usually characterized by a sudden, severe headache.
Choice C. A transient ischemic attack (TIA) is often called a mini-stroke and symptoms are temporary. A sudden, severe headache is more indicative of a hemorrhagic stroke.
Choice D. A hemorrhagic stroke, which involves bleeding within the brain, is most likely to cause a sudden, severe headache, and can lead to seizures and changes in consciousness.
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