The nurse is caring for a client with a chest tube in place. Which finding by the nurse requires further intervention?

Vigorous bubbling in the water seal chamber.

Serosanguineous drainage less than 70 mL/hr in the drainage chamber.

Mild chest discomfort when the client coughs and deep breathes.

Small amount of crepitus around the insertion site.

Answer and Explanation

The Correct Answer is A

Choice A reason: Vigorous bubbling in the water seal chamber indicates an air leak, suggesting a connection between the pleural space and atmosphere, possibly from a dislodged tube or lung tear. This worsens pneumothorax, requiring immediate intervention to locate and correct the leak, restoring pleural integrity and preventing respiratory compromise.

Choice B reason: Serosanguineous drainage less than 70 mL/hr is normal for a chest tube, indicating expected postoperative or pleural fluid drainage. It does not suggest complications like excessive bleeding or infection, so no immediate intervention is required, making this finding benign compared to an air leak.

Choice C reason: Mild chest discomfort during coughing or deep breathing is expected with a chest tube, as it irritates the pleural space. This does not indicate a complication requiring intervention, as it reflects normal tissue response to the tube, manageable with pain relief, not urgent action.

Choice D reason: Small crepitus around the insertion site indicates subcutaneous emphysema, where air escapes into tissues. While concerning, small amounts often resolve spontaneously as the lung heals. It requires monitoring but not immediate intervention, unlike vigorous bubbling, which signals a critical air leak requiring urgent action.

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Correct Answer is B

Explanation

Choice A reason: Administering pain medication is important for comfort but not the most critical action upon PACU transfer. Pain is typically managed in the PACU, and respiratory complications like atelectasis or hypoxia are life-threatening, making respiratory assessment the priority to ensure client stability.

Choice B reason: Assessing respiratory status is critical upon PACU transfer, as postoperative clients risk respiratory complications like atelectasis or airway obstruction from anesthesia. Ensuring adequate oxygenation and ventilation prevents hypoxia, making this the priority to ensure client safety and detect early signs of respiratory distress.

Choice C reason: Checking the surgical dressing assesses for bleeding or infection but is secondary to respiratory status. Wound complications are less immediately life-threatening than respiratory issues, which can cause rapid hypoxia, making dressing checks a lower priority upon transfer to the medical-surgical unit.

Choice D reason: Monitoring urine output assesses renal function and fluid status but is not the most urgent upon PACU transfer. Respiratory complications pose a greater immediate risk, as anesthesia and surgery impair lung function, making respiratory assessment the priority to prevent hypoxia-related complications.

A. Measure the circumference of both upper arms. B. Notify the provider who inserted the PICC line. C. Remove the PICC line. D. Apply a cold pack to the client's upper arm.

Correct Answer is A

Explanation

Choice A reason: Measuring arm circumference quantifies swelling, a sign of complications like thrombosis or infection. Comparing both arms establishes a baseline, aiding in assessing edema severity. This objective data guides interventions, prioritizing assessment before invasive actions, ensuring accurate diagnosis and management of PICC-related issues like venous thrombosis.

Choice B reason: Notifying the provider is important but not the first step. Measuring arm circumference provides objective data to report accurately. Swelling may indicate thrombosis or infection, but without measurements, premature notification lacks specificity, potentially delaying interventions based on clinical findings and diagnostic confirmation.

Choice C reason: Removing the PICC line is premature without confirming the cause of swelling. Thrombosis, infection, or mechanical issues could cause swelling, but removal risks complications like bleeding. Assessment, like measuring arm circumference, is needed first to determine if removal or other interventions are warranted.

Choice D reason: Applying a cold pack may reduce swelling but does not address underlying causes like thrombosis or infection. Without assessing the extent and cause of swelling, this intervention is inappropriate as a first step. Objective data collection, like measuring arm circumference, guides effective treatment and prevents complications.

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The nurse is caring for a client with a chest tube in place. Which finding by the nurse requires further intervention?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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