The nurse is assessing a client with a chest tube following a pneumonectomy. Which assessment finding requires nursing intervention?

Bandage around the posterior tube is loose.

2 cm of water is in the second chest tube chamber.

The water in the water seal chamber rises and falls with inhalation/exhalation.

Bubbling present in the water seal chamber when the client coughs.

Answer and Explanation

The Correct Answer is A

A. A loose bandage around the chest tube compromises the sterile seal of the dressing, which increases the risk of air entering the pleural space and infection. For a client following a pneumonectomy, maintaining a tight, sterile dressing is essential to prevent pneumothorax or subcutaneous emphysema. This finding requires immediate nursing intervention by reinforcing or replacing the dressing and monitoring the site for signs of air leakage or infection.

B. 2 cm of water in the suction control chamber is expected if suction is applied, depending on the prescribed water level. This is normal and indicates proper suction regulation.

C. Fluctuation (tidaling) in the water seal chamber with inhalation and exhalation is expected. It indicates patent drainage and lung re-expansion. Lack of tidaling could indicate tube obstruction, kinking, or lung re-expansion.

D. Intermittent bubbling in the water seal chamber during coughing is normal. It occurs because increased intrathoracic pressure temporarily forces air through the chest tube. Continuous bubbling at rest, however, would indicate an air leak and require intervention.

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Correct Answer is A

Explanation

A. Inward displacement of a rib section during inspirationis correct because flail chest occurs when two or more adjacent ribs are fractured in two or more places, creating a free-floating segment of the chest wall. This segment moves paradoxically, meaning it moves inward during inspiration and outward during expiration, which is the hallmark sign of flail chest. This paradoxical motion impairs ventilation and can lead to respiratory compromise.

B. Continuous outward bulging of a rib section throughout breathingis incorrect because flail chest is defined by paradoxical motion, not constant outward movement. Continuous outward bulging may suggest other chest wall deformities or localized swelling but is not diagnostic of flail chest.

C. Shift of mediastinal structures to affected side during inspirationis incorrect because mediastinal shiftoccurs in tension pneumothorax, not flail chest. In tension pneumothorax, air accumulates in the pleural space, pushing the heart and mediastinum toward the unaffected side, compromising circulation.

D. Deep, inspiratory stridor during inspirationis incorrect because stridor is an upper airway obstruction sign, not a characteristic of flail chest. Flail chest primarily affects ventilation mechanicsand causes paradoxical chest wall movement rather than airway noise.

A. Pain rating of 3 on a scale of 0 to 10 by the client. B. Decreased client anxiety. C. Respiratory rate of 16 breaths/minute. D. PaO2 of 82 mm Hg.

Correct Answer is A

Explanation

A. The primary goal of administering hydromorphone IVis to relieve severe pain. A decrease in the pain score from 8/10 to 3/10 indicates that the analgesic intervention has been effective, allowing improved comfort and potentially better respiratory effort.

B. While reduced anxiety may occur as a secondary effectof pain relief, it is not a direct measureof the effectiveness of the opioid analgesic. Anxiety reduction alone does not confirm pain control.

C. Although maintaining a normal respiratory rate is important, opioids can depress respirations. The rate of 16 may reflect adequate breathing, but it does not directly measure pain relief. The client could still be in pain despite a normal respiratory rate.

D. Improvement in oxygenation may occur as a result of better ventilation after pain control, but it is an indirect indicator. PaO2 can be influenced by factors other than pain, such as the pneumothorax or underlying lung injury, so it does not confirm analgesic effectiveness.

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The nurse is assessing a client with a chest tube following a pneumonectomy. Which assessment finding requires nursing intervention?

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who sustained a blunt chest injury. Which would indicate to the nurse that the client is exhibiting a flail chest?

Correct Answer is A

Explanation

The nurse is caring for a client with rib fractures and a pneumothorax who reports a pain score of 8/10. The nurse administered prescribed hydromorphone IV push and reassesses the client in 30 minutes. What data indicates that the treatment is effective?

Correct Answer is A

Explanation

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