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 B

Explanation

Choice A reason:While sharing needles can transmit hepatitis, it is more commonly associated with hepatitis B and C, not hepatitis A.

Choice B reason:Eating shellfish from contaminated water is a well-known route of transmission for hepatitis A, aligning with the client's symptoms.

Choice C reason:Blood transfusions were a risk for hepatitis transmission in the past, but since the 1990s, blood products are screened for hepatitis, making this an unlikely source.

Choice D reason:Unprotected sex can be a route of transmission for hepatitis, but hepatitis A is more commonly spread through ingestion of contaminated food or water, not sexual contact.

A. "The microwave in my kitchen can warm the solution before I use it." B. "The catheter can become infected even with sterile precautions." C. "The volume of the output solution should be greater than the input solution." D. "The fluid from my abdomen will be clear or slightly yellow."

Correct Answer is A

Explanation

Choice A reason:Using a microwave to warm the solution is not recommended as it can lead to uneven heating and potentially damage the solution or harm the patient.

Choice B reason: The statement about the catheter becoming infected despite sterile precautions is accurate and reflects an understanding of the risks associated with peritoneal dialysis.

Choice C reason:Expecting the volume of the output solution to be greater than the input solution is incorrect; typically, the volumes should be equal to ensure proper fluid removal.

Choice D reason: The fluid from the abdomen being clear or slightly yellow is a normal finding and does not indicate a need for further teaching.

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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

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