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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.2"]
Explanation
- Step 1: Identify the child's weight in pounds. The child weighs 33 lbs.
- Step 2: Convert the child's weight from pounds to kilograms. We know that 1 kg = 2.2 lbs. So, 33 lbs = 33 ÷ 2.2 kg. Calculating the division gives us approximately 15 kg.
- Step 3: Identify the prescribed dose in mcg/kg/day. The child is scheduled to receive 8 mcg/kg/day of digoxin, divided equally every 12 hours.
- Step 4: Calculate the total daily dose in mcg. We can do this by multiplying the child's weight in kg by the prescribed dose in mcg/kg:
- Total daily dose = 8 mcg/kg/day × 15 kg.
- Calculating the multiplication gives us: Total daily dose = 120 mcg/day.
- Step 5: Since the dose is divided equally every 12 hours, we divide the total daily dose by 2 to get the dose per administration:
- Dose per administration = Total daily dose ÷ 2.
- Dose per administration = 120 mcg ÷ 2.
- Calculating the division gives us: Dose per administration = 60 mcg.
- Step 6: Identify the concentration of the available solution. The available solution contains 0.05 mg/mL of digoxin. Convert this to mcg/mL for consistency with the dose per administration. We know that 1 mg = 1000 mcg. So, 0.05 mg = 0.05 × 1000 mcg = 50 mcg/mL.
- Step 7: Calculate the volume of solution needed to deliver the required dose. We can set up a proportion to solve for this:
- 50 mcg is to 1 mL as 60 mcg is to X mL.
- In other words, 50 mcg : 1 mL = 60 mcg : X mL.
- Step 8: Solve for X using cross-multiplication and division:
- Cross-multiplication gives us: 50 mcg × X mL = 60 mcg × 1 mL.
- Simplifying this gives us: 50X = 60.
- Dividing both sides by 50 gives us: X = 60 ÷ 50.
- Calculating the division gives us: X = 1.2.
Administer 1.2 mL of the digoxin elixir per dose.
Correct Answer is ["A","B","D"]
Explanation
Title: Choice A reason: Beta-blocking agent Beta-blocking agents are often used in the management of cirrhosis of the liver. They are particularly useful in managing portal hypertension, a common complication of cirrhosis. Beta-blockers lower elevated portal pressure and protect against variceal hemorrhage, a serious complication of portal hypertension. Therefore, a beta-blocking agent may be ordered for a client with cirrhosis of the liver.
Title: Choice B reason: Diuretic Diuretics are commonly used in the management of fluid retention, a frequent complication in patients with cirrhosis. Fluid retention can lead to conditions such as ascites (abdominal fluid accumulation) and edema (swelling in the legs, feet, or ankles)2. Diuretics help to remove excess fluid from the body, thereby managing these symptoms. Therefore, a diuretic may be ordered for a client with cirrhosis of the liver.
Title: Choice C reason: Opioid analgesic While opioid analgesics are powerful pain relievers, they should be used with caution in patients with cirrhosis of the liver. Opioids can precipitate hepatic encephalopathy, a condition characterized by altered mental status and neuromuscular dysfunction, which is a serious complication of cirrhosis. Therefore, an opioid analgesic may not be the best choice for a client with cirrhosis of the liver.
Title: Choice D reason: Lactulose Lactulose is a non-absorbable sugar that is widely used in the treatment of hepatic encephalopathy, a common complication in patients with cirrhosis. It works by reducing the absorption of ammonia in the gut, thereby lowering blood ammonia levels and improving symptoms of hepatic encephalopathy. Therefore, lactulose may be ordered for a client with cirrhosis of the liver.
Title: Choice E reason: Sedative Sedatives should be used with caution in patients with cirrhosis of the liver. Like opioids, they can precipitate hepatic encephalopathy. Therefore, a sedative may not be the best choice for a client with cirrhosis of the liver.
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