The nurse assesses a client with a chest tube inserted to treat pneumothorax. Which assessment finding best indicates that a chest tube is no longer needed?

Arterial blood gas results are within normal range.

There is no fluctuation in the water seal chamber

The client states he is not experiencing dyspnea.

There is minimal drainage from the chest tube.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Normal ABG values indicate adequate gas exchange, but they do not confirm that the lung has fully re-expanded or that air and fluid are no longer accumulating in the pleural space. ABGs alone are insufficient to determine chest tube removal.

B. Fluctuation, or “tidaling,” in the water seal chamber reflects pleural pressure changes during respiration. When the lung has re-expanded and the pneumothorax has resolved, there is no longer a pressure change, and the water seal chamber ceases to fluctuate. This is the most reliable clinical indicator that the chest tube is no longer needed.

C. Absence of shortness of breath is reassuring, but it is subjective and does not confirm lung re-expansion or cessation of air/fluid leakage in the pleural space. Relying on symptoms alone is insufficient for chest tube removal.

D. Minimal drainage indicates decreased fluid output, but even with minimal drainage, air leaks may persist. The presence or absence of tidaling and air leak assessment is more important than fluid output in determining removal readiness.

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Free Nursing Study Resources

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

Rationale:
The glucose level is correct for the first blank because a blood glucose of 250 mg/dL indicates hyperglycemia, which is a common complication of acute pancreatitis due to impaired insulin production. Hyperglycemia requires immediate nursing intervention to prevent further metabolic complications.

The Hgb & Hct level is correct for the second blank because the hemoglobin of 8 g/dL and hematocrit of 24% indicate significant anemia, which may suggest hemorrhage or fluid shifts associated with severe pancreatitis. This abnormal finding requires prompt notification of the provider for further evaluation and management.

The lipase level is incorrect because although elevated, lipase confirms the diagnosis of pancreatitis and does not require immediate intervention once identified.

The amylase level is incorrect because it is also elevated and supports the diagnosis but is not the priority compared to correcting hyperglycemia and addressing significant anemia.

A. New onset of lightheadedness B. Complaints of right shoulder pain C. Heart rate of 116 beats per minute D. Requesting more water to drink E. A wide pulse pressure F. Respiratory rate of 28 breaths per minute

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

Explanation

Rationale:

A. New onset of lightheadedness is a key sign of hypovolemia due to internal bleeding. Blood loss decreases circulating volume, leading to decreased perfusion to the brain and dizziness or syncope. This supports the suspicion of internal hemorrhage from liver trauma.

B. Complaints of right shoulder pain (Kehr’s sign) can indicate referred pain from diaphragmatic irritation due to blood in the peritoneal cavity, commonly associated with liver or spleen trauma. This is an important clinical cue supporting internal bleeding.

C. Heart rate of 116 beats per minute indicates tachycardia, a compensatory response to hypovolemia. The body increases heart rate to maintain cardiac output when blood volume decreases, which is consistent with bleeding.

D. Requesting more water to drink is not directly related to liver trauma or internal bleeding. While thirst may occur with mild fluid loss, it is nonspecific and not a reliable cue for acute hemorrhage.

E. A wide pulse pressure (the difference between systolic and diastolic BP) is not typically associated with acute hemorrhage. In early blood loss, blood pressure is often normal or low-normal, and pulse pressure may narrow, not widen.

F. Respiratory rate of 28 breaths per minute indicates tachypnea, which can occur as a compensatory mechanism for hypovolemia and tissue hypoxia. Increased respiratory rate helps improve oxygen delivery when perfusion is compromised due to bleeding.

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The nurse assesses a client with a chest tube inserted to treat pneumothorax. Which assessment finding best indicates that a chest tube is no longer needed?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has acute pancreatitis. Complete the following sentence by using the list of options. When prioritizing client needs, the nurse should first address the client's dropdown followed by notifying the provider of the client's dropdown

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

The nurse suspects that a client who presented to the emergency department is experiencing bleeding from liver trauma, Which cues support the nurse's suspicion? Select all that apply.

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

Explanation

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