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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Encourage the client to be assertive is correct. Encouraging assertiveness is important for a client with dependent personality disorder (DPD., as they often have difficulty making decisions or taking initiative. Teaching the client to express their needs, opinions, and desires is a key part of treatment and helps promote independence.
B. Maintain a verbal no-harm contract with the client is incorrect. While maintaining a no-harm contract may be appropriate for clients at risk for self-harm, this is not specific to dependent personality disorder. The main goal is to promote independence and healthy decision-making, not just ensuring safety.
C. Limit the client's social interactions is incorrect. In fact, encouraging healthy social interactions and gradual independence from others is often an important part of treatment for DPD. Limiting interactions could reinforce dependency and hinder progress.
D. Assume responsibility for making the client's decisions is incorrect. The nurse should encourage the client to make their own decisions and foster independence, rather than taking over their decisions, which could worsen the dependent behaviors.
Correct Answer is B
Explanation
A. "I can take antacids at the same time as this medication.": This is incorrect. Pantoprazole is a proton pump inhibitor (PPI), and taking antacids at the same time can interfere with the medication's effectiveness. It is generally recommended to space out antacids and PPIs by at least 1 hour.
B. "I have to take this medication on an empty stomach.": This is correct. Pantoprazole should be taken on an empty stomach, typically 30 minutes before breakfast, to optimize absorption and effectiveness.
C. "I should expect to have diarrhea while taking this medication.": Diarrhea is not a common side effect of pantoprazole. While side effects such as headache, nausea, and abdominal pain are more common, diarrhea is not typically expected.
D. "I will need to remain upright for 1 hour after taking the medication.": This is incorrect. While it is generally advised to remain upright for a period after taking medications like bisphosphonates, it is not required for pantoprazole. The main instruction for pantoprazole is to take it on an empty stomach before eating.
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