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. Initiates speech rarely: This is a negative symptom of schizophrenia, where the individual may exhibit a lack of motivation or interest in social interaction, leading to reduced speech or verbal communication. Negative symptoms refer to the absence or decrease of normal functioning or behaviors, such as lack of speech, emotional expression, or motivation.
B. Has a preoccupation with religious thoughts: This is more of a positive symptom, potentially indicating delusions or hallucinations. Positive symptoms involve the presence of abnormal thoughts or behaviors.
C. Mimics the nurse's movements: This behavior, called echopraxia, is a positive symptom of schizophrenia, which involves involuntary imitation of another person's movements.
D. Smells odors that don't exist: This is a hallucination, which is a positive symptom of schizophrenia. Hallucinations are sensory perceptions without external stimuli, such as hearing voices or smelling things that aren’t there.
Correct Answer is A
Explanation
A. A negative pressure room is correct. Varicella zoster, which causes chickenpox, is an airborne virus. Therefore, airborne precautions are required, which include placing the client in a negative pressure room to prevent the spread of the virus to other areas of the facility.
B. Administering aspirin is incorrect. Aspirin should not be given to children or adolescents with varicella zoster due to the risk of Reye's syndrome. Instead, an antipyretic such as acetaminophen should be used to treat fever.
C. Contact precautions are not sufficient for varicella zoster, as the virus requires airborne precautions to prevent transmission through the air.
D. Having visitors remain at least 0.91 m (3 feet) away is incorrect. Airborne precautions require that visitors wear appropriate PPE, including respirators, and should not be restricted to 3 feet away. Ideally, visitors should wear full protective gear when entering the room.
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