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 D

Explanation

A. Avoiding crowded places such as public transportation during peak hours: Avoiding crowded areas can help reduce exposure to infections, but it is not the most critical aspect of self-care. Clients cannot always fully avoid public spaces, and prevention strategies must be more comprehensive.

B. Appropriate use of prophylactic antibiotics: Some clients with HIV may be prescribed prophylactic antibiotics to prevent opportunistic infections. However, this is provider-directed and not a universal measure for all clients. Teaching should emphasize broader, daily self-care practices.

C. Taking prescribed medications with food to reduce gastrointestinal upset: Taking medications with food can help manage side effects and improve adherence, but this is secondary to infection prevention. GI upset is manageable, whereas infections can quickly become life-threatening.

D. Maintaining strict personal hygiene practices: Clients with HIV are immunocompromised and highly susceptible to infections. Proper handwashing, safe food handling, and skin/mouth care are essential in reducing exposure to pathogens and preventing serious complications.

A. High self awareness B. Impaired relationships C. Empathy for others D. Motivation to change

Correct Answer is B

Explanation

A. High self-awareness: Clients with personality disorders often have limited insight into their behaviors and how these affect others. They may not recognize their maladaptive patterns, making high self-awareness uncommon in this population.

B. Impaired relationships: Personality disorders are marked by enduring maladaptive patterns of behavior and cognition, which significantly disrupt interpersonal functioning and lead to unstable, strained, or impaired relationships.

C. Empathy for others: Many personality disorders, especially antisocial or narcissistic types, involve difficulty with empathy. Even in other types, clients may be so preoccupied with their own distress that empathy is diminished.

D. Motivation to change: Clients with personality disorders often lack motivation to change because they do not perceive their behavior as problematic. Change typically occurs only when external pressures, such as legal, social, or health consequences, force them to seek help.

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While 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

A client with HIV is being discharged home and will begin receiving care in the home setting. During discharge education, which aspect of self-care should the nurse emphasize as the priority to help prevent complications?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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