While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication?

Bloody drainage is observed in the collection chamber.

Skin around tube is pink.

Absence of bloody drainage in the anterior/upper tube

The tissues around the tube give a crackling sensation when palpated.

Answer and Explanation

The Correct Answer is D

A. Bloody drainage is observed in the collection chamber: Some bloody drainage is expected, especially in the initial postoperative or post-injury phase. It becomes concerning only if there is a sudden increase or massive blood loss, but in general, the presence of bloody drainage alone is not necessarily a complication.

B. Skin around tube is pink: Pink skin around the chest tube insertion site is generally a normal finding and may indicate mild irritation from dressing or tape.

C. Absence of bloody drainage in the anterior/upper tube: The anterior/upper chest tube is usually placed for air removal, not fluid. Therefore, it is normal for this tube to have little or no drainage, and absence of fluid does not indicate a complication.

D. The tissues around the tube give a crackling sensation when palpated: This finding indicates subcutaneous emphysema, where air has leaked into the subcutaneous tissue. It suggests a possible air leak or malfunction in the chest tube system, and requires further assessment and intervention.

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Correct Answer is C

Explanation

A. Pleural effusion: This involves fluid accumulation in the pleural space, leading to diminished breath sounds and dyspnea. However, it typically develops gradually, not with sudden onset following trauma.

B. Asthma exacerbation: Asthma usually presents with wheezing, prolonged expiration, and airway inflammation. The absence of wheezing and the presence of unequal chest excursion make this less likely.

C. Pneumothorax: Sudden chest pain, dyspnea, decreased breath sounds, and unequal chest excursion strongly suggest pneumothorax. The history of trauma increases the likelihood, as air enters the pleural space causing lung collapse.

D. Pulmonary embolism: This causes sudden dyspnea and chest pain, but breath sounds are usually normal or clear. The presence of trauma, decreased breath sounds, and unequal chest expansion makes pulmonary embolism less consistent with this case.

A. The importance of adhering closely to the prescribed medication regimen B. The client should wear a surgical mask in public for a year following diagnosis due to latent TB C. The client may return to work once symptoms improve and they feel well enough. D. Household members should begin prophylactic antibiotic treatment immediately

Correct Answer is A

Explanation

A. The importance of adhering closely to the prescribed medication regimen: Active TB requires long-term multidrug therapy, and adherence is crucial to prevent relapse, ongoing transmission, and development of multidrug-resistant TB. Incomplete treatment is a major public health risk.

B. The client should wear a surgical mask in public for a year following diagnosis due to latent TB: Clients with latent TB are not contagious, and mask use for an entire year is unnecessary. Mask use is important only during the initial infectious phase of active TB until sputum smears are negative.

C. The client may return to work once symptoms improve and they feel well enough: Symptom improvement does not mean the client is no longer infectious. Return to work is only appropriate when the client has completed adequate therapy and has documented negative sputum cultures.

D. Household members should begin prophylactic antibiotic treatment immediately: Not all household members automatically require prophylaxis. They should first undergo TB testing, and only those with positive results or who are high-risk will be prescribed preventive therapy.

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While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is A

Explanation

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