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. "Provide homeschooling for your child" is not a necessary instruction. Children with cystic fibrosis can attend school, and with appropriate care, they can often manage their condition and participate in normal activities.

B. "Have your child wear a medical identification wristband" is correct. A medical identification wristband is important for children with cystic fibrosis as it can provide crucial information in an emergency, such as their diagnosis and specific care needs.

C. "Ensure that your child does not receive the influenza vaccine annually" is incorrect. Children with cystic fibrosis are at higher risk for respiratory complications and should receive the influenza vaccine annually to help prevent infection and reduce the risk of exacerbations.

D. "Do not include your child when making decisions about treatment" is incorrect. Involving children in their treatment decisions, as appropriate for their age and understanding, is important for fostering autonomy and ensuring they feel empowered in managing their condition.

A. Hold the irrigation solution bottle 5 cm (2 in) above the sterile container. B. Open the outer wrapper of the sterile package toward her body. C. Place the irrigation solution bottle cap on the sterile field. D. Place sterile objects at least 2.5 cm (1 in) from the edge of the sterile field.

Correct Answer is D

Explanation

A. Holding the irrigation solution bottle 5 cm (2 in) above the sterile container is incorrect because the solution should be poured into a sterile container without contaminating the sterile field. The nurse should pour the solution from a height that avoids splashing and contamination.

B. Opening the outer wrapper of the sterile package toward her body is incorrect. The outer wrapper of a sterile package should be opened away from the body to avoid contamination of the sterile field.

C. Placing the irrigation solution bottle cap on the sterile field is incorrect. The cap should not be placed on the sterile field, as it may introduce contaminants.

D. Placing sterile objects at least 2.5 cm (1 in) from the edge of the sterile field is correct. This practice maintains the sterility of the field by preventing contamination from external sources.

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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

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