A nurse is caring for a client who has a chest tube that was inserted 4 days ago. Which of the following findings should the nurse report to the charge nurse?

Respiratory rate 16/min

Blood pressure 110/70 mm Hg

400 mL of drainage in the collection chamber within 4 hr

Fluctuation in the water seal chamber with respiration

Answer and Explanation

The Correct Answer is C

A. Respiratory rate 16/min is a normal finding. A respiratory rate of 16/min is within the expected range for adults, so it does not indicate a problem that requires immediate attention.

B. Blood pressure 110/70 mm Hg is within the normal range for blood pressure. This is an acceptable finding and does not require reporting to the charge nurse.

C. 400 mL of drainage in the collection chamber within 4 hr should be reported to the charge nurse. This is an excessive amount of drainage for a client with a chest tube. After the first few hours post-surgery, the drainage should decrease. Large amounts of drainage may indicate bleeding, and it is important to notify the charge nurse immediately to assess the situation further.

D. Fluctuation in the water seal chamber with respiration is a normal finding. It is expected for the water seal chamber to fluctuate with the client’s respirations, indicating that the chest tube is functioning properly and the system is not obstructed.

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Correct Answer is B

Explanation

A. "Our child has a better grasp of reality.": This is not the primary goal of methylphenidate. While it may help with focus and attention, the medication's goal is to improve concentration and reduce hyperactive behaviors in children with ADHD, not directly influence their grasp of reality.

B. "Our child is able to complete his homework on time.": This is correct. Methylphenidate, a stimulant used to treat ADHD, helps improve attention, focus, and impulse control. A child who can complete homework on time demonstrates improved attention and task completion, which is the desired outcome.

C. "Our child has lost some weight since his last appointment.": While weight loss can be a side effect of methylphenidate, it is not an indicator that the medication is effective. The goal is to manage ADHD symptoms, not necessarily to cause weight loss.

D. "Our child has increased his daily caloric intake.": This is incorrect. A common side effect of methylphenidate is decreased appetite, so an increase in caloric intake would not be expected.

A. Allow the antiseptic to dry before puncturing. B. Apply sterile gloves. C. Hold the lancet at a 45° angle. D. Massage the client's finger away from the puncture site.

Correct Answer is A

Explanation

A. Allow the antiseptic to dry before puncturing.: This is correct. It is important to allow the antiseptic (such as alcohol) to dry before puncturing the skin. If the antiseptic is not allowed to dry, it can cause hemolysis of the blood sample and lead to inaccurate glucose readings.

B. Apply sterile gloves.: This is incorrect. While gloves should be worn to maintain hygiene and safety, non-sterile gloves are sufficient for a capillary blood glucose test. Sterile gloves are not necessary unless the procedure requires aseptic technique.

C. Hold the lancet at a 45° angle.: This is incorrect. The lancet should be held at a 90° angle to the skin to ensure a proper and clean puncture.

D. Massage the client's finger away from the puncture site.: This is incorrect. The finger should not be massaged before or after the puncture site because it can cause tissue damage and lead to inaccurate blood samples due to the mixing of interstitial fluid with the blood sample.

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A nurse is caring for a client who has a chest tube that was inserted 4 days ago. Which of the following findings should the nurse report to the charge nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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