Patient Data

Exhibits

Which are important to monitor in this client following the chest tube placement? Select all that apply.

Chest circumference

Arterial blood gas (ABG) results

Bubbling in the water seal chamber

Daily weights

Peak flow meter values

Developmentally appropriate pain rating

Answer and Explanation

Correct Answer : B,C,F

Rationale:
A. Chest circumference: Measuring chest circumference is typically used to monitor for bleeding or swelling in infants or postoperative chest surgery patients, not in routine chest tube monitoring. It provides limited information about respiratory function or tube effectiveness in this adult client.

B. Arterial blood gas (ABG) results: ABGs help assess oxygenation, ventilation, and acid-base balance following chest tube placement. They are essential to determine whether the lung is adequately re-expanded and gas exchange is improving after a pneumothorax or effusion.

C. Bubbling in the water seal chamber: Bubbling in the water seal chamber indicates air movement within the pleural space. Continuous bubbling suggests an air leak, while intermittent bubbling may occur during expiration. Monitoring this helps assess chest tube function and detect complications.

D. Daily weights: Although useful for tracking fluid balance, daily weights are not directly relevant to evaluating chest tube effectiveness or respiratory status in this context. They do not reflect immediate pulmonary improvements.

E. Peak flow meter values: Peak flow measurement is typically used in asthma or obstructive airway disorders to monitor expiratory effort. It is not an appropriate indicator of lung re-expansion or pleural drainage after chest tube insertion.

F. Developmentally appropriate pain rating: Pain can interfere with breathing, coughing, and mobility, leading to poor lung expansion. Monitoring pain using a tool appropriate for the client’s developmental level ensures comfort and promotes effective respiratory function post-procedure.

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Correct Answer is ["B","C","E","F"]

Explanation

Rationale:
A. Call for a stat chest x-ray: Although confirming the suspected pneumothorax with imaging is necessary, this action should follow immediate life-saving interventions. The client is already cyanotic and unstable, requiring oxygenation and airway support before diagnostic imaging.

B. Collect supplies for a chest tube: The absence of breath sounds and chest rise on one side after thoracentesis strongly suggests a pneumothorax. Preparing chest tube supplies ensures that the healthcare provider can promptly insert the tube to re-expand the lung and restore ventilation.

C. Suction the client: Since the client has a tracheostomy and thick secretions, airway obstruction may worsen hypoxia. Suctioning helps clear mucus, improve airflow, and facilitate oxygen delivery while awaiting further intervention.

D. Replace the tracheostomy tube: Replacing the tracheostomy tube is not indicated unless it is dislodged or blocked, which is not stated in the scenario. Unnecessary manipulation could cause further airway compromise or trauma.

E. Increase the client’s oxygen: Cyanosis indicates severe hypoxia, requiring immediate oxygen escalation to the highest safe concentration. Increasing FiO₂ helps stabilize oxygen saturation while the underlying cause is corrected.

F. Place the client on a continuous pulse oximeter: Continuous pulse oximetry provides real-time monitoring of oxygenation status and helps evaluate the effectiveness of interventions. This allows for early detection of worsening hypoxia and guides rapid response efforts.

A. Poor cough, diaphragmatic breathing. B. Absence of sensory and motor function. C. Paraplegia. D. Intact sensory but absent motor function. E. Tetraplegia (quadriplegia).

Correct Answer is ["A","B","E"]

Explanation

Rationale:
A. Poor cough, diaphragmatic breathing: Cervical spinal cord injuries can impair innervation of the diaphragm and accessory muscles, resulting in weak cough and compromised respiratory effort. This is common with high cervical transections and can lead to respiratory complications.

B. Absence of sensory and motor function: A complete transection at the cervical level causes total loss of voluntary motor function and sensation below the level of injury. Both sensory and motor deficits are hallmark features of complete spinal cord injury.

C. Paraplegia: Paraplegia involves paralysis of the lower extremities, typically resulting from thoracic, lumbar, or sacral injuries. It is not characteristic of high cervical cord transection.

D. Intact sensory but absent motor function: This describes a condition such as anterior cord syndrome or incomplete spinal cord injury. Complete transection affects both motor and sensory pathways, so this pattern is inconsistent.

E. Tetraplegia (quadriplegia): Injury at the cervical level affects all four extremities, resulting in tetraplegia. This is a primary manifestation of complete cervical cord transection.

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Patient Data Exhibits Which are important to monitor in this client following the chest tube placement? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits The rapid response team (RRT) is on its way to the bedside. Which 4 actions should the nurse perform immediately?

Correct Answer is ["B","C","E","F"]

Explanation

The nurse is caring for a client who is admitted with head and neck injury following a motor vehicle accident. The nurse should identify which clinical manifestation(s) are associated with a complete transection of the cervical spinal cord? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

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Patient Data Exhibits The primary nurse reviews the client's history and vital signs. Select the 3 priority assessment findings that require immediate follow up.

Patient Data Exhibits The nurse notifies the healthcare provider of the client's status. The healthcare provider comes to the bedside to evaluate the client. Which should the nurse do? Select all that apply.

Patient Data

Exhibits

Which are important to monitor in this client following the chest tube placement? Select all that apply.