A client with a hemothorax has a chest tube in the fourth intercostal space connected to suction at 20 cm H2O pressure. Four hours after insertion, which client outcome should the nurse consider to be within normal limits for this client?

Fluctuation with respiration in the water-seal chamber of the

The dry gauze dressing over the insertion site is clean and intact.

No bubbling in the suction chamber of the Pleura.

Serous fluid in the drainage chamber of the Pleura.

Answer and Explanation

The Correct Answer is A

Choice A: Fluctuation with respiration in the water-seal chamber of the chest drainage system is a normal and expected finding for a client with a chest tube in place. It indicates that the system is functioning correctly and allows for the removal of air or fluid from the pleural space during inspiration and expiration.

Choice B: The condition of the dry gauze dressing over the insertion site is important for monitoring any potential signs of infection or bleeding but does not directly relate to the functioning of the chest tube.

Choice C: No bubbling in the suction chamber of the Pleur-Evac system may indicate that the suction pressure is not adequately transmitted to the chest tube or that there is an issue with the system's seal. This finding is not within normal limits and should be addressed.

Choice D: The presence of serous fluid in the drainage chamber of the Pleur- Evac system is expected and indicates that drainage from the pleural space is occurring. However, the key assessment for proper chest tube function is the fluctuation in the water-seal chamber with respiration.

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Correct Answer is B

Explanation

Choice A: Weight loss history and body surface area (BSA) are relevant factors to consider when assessing nutritional status, but they are not the most indicative parameters on their own.

Choice B: Body mass index (BMI) and serum albumin level are two of the most indicative parameters for assessing nutritional status. BMI provides information about body weight relative to height, while serum albumin level is a common marker of nutritional status and protein intake.

Choice C: Triceps skinfold and mid-arm circumference are anthropometric measurements that can provide additional information about muscle and fat stores in the body, but they are not as widely used or as indicative as BMI and serum albumin level.

Choice D: 24-hour food recall, food preferences, and allergies are important to assess but do not provide immediate indicators of nutritional status. They are valuable for understanding dietary habits and preferences.

A. Salad greens with tomatoes. B. One slice of cheese pizza. C. Roasted turkey sandwich. D. Baked potato with low fat butter

Correct Answer is C

Explanation

Choice A: Salad greens with tomatoes do not provide a significant source of protein.

Choice B: One slice of cheese pizza may contain saturated fats from cheese and processed meats, so it may not be the best choice if the goal is to reduce saturated fat intake.

Choice C: A roasted turkey sandwich can be a good alternative source of protein without the same level of saturated fats found in hamburgers. Turkey is typically leaner than beef, and if prepared without excessive fats or sauces, it can be a healthier choice.

Choice D: Baked potato with low-fat butter is primarily a source of carbohydrates and fats but does not provide a significant source of protein.

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A client with a hemothorax has a chest tube in the fourth intercostal space connected to suction at 20 cm H2O pressure. Four hours after insertion, which client outcome should the nurse consider to be within normal limits for this client?

Nursing Test Bank

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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