The nurse is caring for a client with a chest tube. Which nursing assessment would alert the nurse to a possible complication?

Skin around tube is pink.

The tissues give a crackling sensation when palpated.

Absence of bloody drainage in the anterior/upper tube

Bloody drainage is observed in the collection chamber.

Answer and Explanation

The Correct Answer is B

A. Skin around tube is pink: Pink, healthy-appearing skin suggests normal circulation and lack of infection or irritation. This is an expected finding and does not indicate a complication related to chest tube placement or function.
B. The tissues give a crackling sensation when palpated: This is indicative of subcutaneous emphysema, a complication where air leaks into the subcutaneous tissue. It feels like bubble wrap under the skin and may signal a chest tube malfunction or air leak in the system.
C. Absence of bloody drainage in the anterior/upper tube: The anterior/upper chest tube typically drains air, not fluid or blood. The absence of bloody drainage here is expected and not cause for concern unless paired with respiratory distress.
D. Bloody drainage is observed in the collection chamber: Bloody drainage may be expected postoperatively, especially after thoracic surgery. It should be monitored for amount and rate, but its presence alone is not necessarily a complication.

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Correct Answer is C

Explanation

A. Facial burns: Facial burns may occur with methods of drug use, such as smoking crack cocaine, but they are not the most urgent concern during withdrawal. Physical injuries are important but do not guide immediate safety-related nursing priorities.
B. Perforated septum: A perforated nasal septum results from chronic intranasal cocaine use. While it indicates long-term damage, it is not a critical issue during the acute withdrawal phase and does not require urgent intervention.
C. Suicide precautions: Cocaine withdrawal is often associated with severe depression, anxiety, and suicidal ideation. Suicide precautions are essential because of the high risk for self-harm, making this the top priority in nursing care.
D. Nutritional support: Cocaine users may suffer from malnutrition due to poor appetite and lifestyle, but nutritional support is not the immediate concern during withdrawal. Safety and mental health monitoring take precedence.

A. "Do you eat three meals per day?" B. "Who eats meals with you?" C. "Do you snack in the evening?" D. "How do you prepare your food?"

Correct Answer is D

No explanation

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The nurse is caring for a client with a chest tube. Which nursing assessment would alert the nurse to a possible complication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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