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 A

Explanation

Choice A reason: A sodium level of 121 mEq/L indicates severe hyponatremia, risking seizures due to cerebral edema from low osmolality. Seizure precautions (e.g., padded rails, anticonvulsants) protect from injury during potential seizures, making this the priority to ensure safety before correcting sodium levels.

Choice B reason: Educating on high-sodium foods is a long-term strategy for hyponatremia but not the priority. Severe hyponatremia (121 mEq/L) risks seizures, requiring immediate protective measures like seizure precautions over dietary education, which addresses chronic management rather than acute neurological risks.

Choice C reason: Administering 3% sodium chloride corrects hyponatremia but is not the first priority. Rapid correction risks osmotic demyelination, and seizure precautions are needed to protect against cerebral edema-induced seizures, a more immediate risk in severe hyponatremia, before initiating sodium therapy.

Choice D reason: A 1-liter-per-day fluid restriction addresses fluid overload in hyponatremia but is secondary to seizure precautions. Severe hyponatremia (121 mEq/L) risks neurological complications like seizures, making immediate safety measures the priority over fluid restriction, which is a slower corrective strategy.

A. Hypovolemia B. Hypernatremia C. Hypokalemia D. Metabolic acidosis

Correct Answer is A

Explanation

Choice A reason: Hypovolemia is likely, as vomiting and diarrhea cause significant fluid loss, leading to dehydration. Confusion (from cerebral hypoperfusion), elevated temperature (from concentrated blood), and dry mouth (from reduced saliva) reflect low intravascular volume, making this the most fitting diagnosis for the client’s condition.

Choice B reason: Hypernatremia results from excessive sodium relative to water, often from inadequate water intake. Vomiting and diarrhea deplete water and electrolytes, causing hypovolemia, not sodium excess. Confusion and fever align with dehydration, making hypernatremia an incorrect diagnosis in this scenario.

Choice C reason: Hypokalemia may occur with diarrhea due to potassium loss, but confusion, fever, and dry mouth primarily reflect hypovolemia from fluid loss. Potassium loss is secondary, as hypovolemia’s systemic effects are more immediate, making this a less comprehensive diagnosis for the client’s symptoms.

Choice D reason: Metabolic acidosis can occur with diarrhea due to bicarbonate loss, but confusion, fever, and dry mouth primarily reflect hypovolemia from fluid loss. Acidosis may contribute, but hypovolemia drives these systemic signs, making it the more accurate diagnosis in this context.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has a sodium level of 121 mEq/L. What is the priority nursing intervention?

Correct Answer is A

Explanation

A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client’s spouse became alarmed when the client demonstrated confusion and elevated temperature and reported “dry mouth.” The nurse suspects the client is experiencing which condition?

Correct Answer is A

Explanation

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