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: Tracheal deviation toward the unaffected side indicates a tension pneumothorax, where air trapped in the pleural space compresses the lung and mediastinum, impairing venous return and cardiac output. This life-threatening condition requires immediate provider notification to prevent cardiovascular collapse and ensure urgent intervention.

Choice B reason: Intermittent minor bubbling in the water seal chamber is normal, indicating air escaping from the pleural space as the pneumothorax resolves. This does not require immediate provider notification unless it becomes vigorous, suggesting a new or worsening air leak, unlike tracheal deviation.

Choice C reason: Crepitus around the insertion site suggests subcutaneous emphysema, where air leaks into tissues. Small amounts often resolve spontaneously as the lung heals, requiring monitoring but not immediate notification, unlike tracheal deviation, which signals a critical tension pneumothorax needing urgent action.

Choice D reason: Difficulty coping with the chest tube is a psychosocial issue, not a physiological emergency. It warrants nursing support but not immediate provider notification, as it does not pose an immediate threat like tracheal deviation, which indicates a life-threatening tension pneumothorax.

A. A client who has a urine specific gravity of 1.010 B. A client who has a weight gain of 2.6 lbs in 24 hours C. A client who has a hematocrit of 45% D. A client who has a BUN of 24 mg/dL

Correct Answer is D

Explanation

Choice A reason: Urine specific gravity of 1.010 is normal (1.005–1.030), indicating adequate hydration. Dehydration elevates specific gravity (>1.030) due to concentrated urine, so this client does not show dehydration signs, making this an incorrect choice for requiring fluid replacement interventions.

Choice B reason: Weight gain of 2.6 lbs in 24 hours suggests fluid retention, not dehydration. This may indicate hypervolemia, possibly from heart or renal failure, requiring diuretics. Dehydration involves weight loss, making this client’s finding inconsistent with dehydration needing intervention.

Choice C reason: Hematocrit of 45% is normal (38–50% males, 36–46% females). Dehydration elevates hematocrit due to hemoconcentration from reduced plasma volume. Normal hematocrit does not indicate dehydration, making this client an incorrect choice for requiring dehydration-specific fluid interventions.

Choice D reason: A BUN of 24 mg/dL is elevated (normal 7–20 mg/dL), indicating dehydration, as reduced renal perfusion concentrates blood urea nitrogen. This reflects hypovolemia, requiring fluid replacement to restore renal function and prevent acute kidney injury, making this client the priority for dehydration intervention.

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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 nurse is assessing a client who has a pneumothorax with a chest tube in place. What assessment would warrant notifying the provider?

Correct Answer is A

Explanation

A nurse is assessing four clients. Which client requires interventions for dehydration?

Correct Answer is D

Explanation

A preceptor advises the novice nurse to prioritize which client intervention?

A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery. The nurse understands that the JP drain was placed for which purpose?

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?

The nurse is educating a client at risk for hypervolemia for self-management at home. Which statement by the client indicates a need for further teaching?

Following admission of the postoperative client to the clinical unit, which of the following assessment data requires the most immediate attention?

The nurse is caring for a client with a new tracheostomy. What will the nurse prioritize for care?

A nurse is assessing a postoperative client for atelectasis. Which signs/symptoms of atelectasis require intervention? (Select all that apply)

A nurse is caring for a client who has a sodium level of 120 mEq/L. Which solution should the nurse prepare to infuse for this client?