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: Teaching clients about the potential side effects of antipsychotic drugs is important, but it is not the most critical aspect of medication administration policy. Monitoring for side effects and adverse reactions is typically the responsibility of healthcare providers and nursing staff.

Choice B: Monitoring all clients receiving antipsychotic drugs for indications of tardive dyskinesia is a crucial standard to include in the policy. Tardive dyskinesia is a serious side effect associated with long-term use of antipsychotic medications, and early detection and intervention are essential to prevent its progression.

Choice C: Ensuring that all clients treated with antipsychotic drugs receive prompt renewals as needed is important for continuity of care, but it is not the primary focus of a policy for administering antipsychotic medications.

Choice D: Documenting all client therapeutic serum levels related to antipsychotic medications is relevant but may not apply to all clients receiving these medications. Monitoring for side effects and adverse reactions is generally more universally applicable and critical to patient safety.

A. Pureed regular diet. B. High protein soft diet. C. Mechanical soft diet. D. Low residue diet.

Correct Answer is C

Explanation

Choice A: A pureed regular diet may not provide enough nutritional support for a client who has lost 25% of their body weight and is experiencing stomatitis. This diet may not have the necessary nutrients to address the client's nutritional needs.

Choice B: A high protein soft diet may be appropriate for some clients, but it may still be challenging for a client with stomatitis to consume. Additionally, the focus should also be on providing adequate overall nutrition, not just protein.

Choice C: A mechanical soft diet is often recommended for clients with stomatitis because it provides foods that are easier to chew and swallow while still offering a variety of nutrients. It is a suitable option for clients who have difficulty eating due to oral mucositis (stomatitis).

Choice D: A low residue diet may not provide sufficient nutrients for a client who has lost 25% of their body weight and is experiencing difficulty eating due to stomatitis. This diet may be too restrictive for their nutritional needs.

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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

Naxlex Comprehensive Predictor Exams

The nurse manager of a community mental health treatment facility is establishing a policy for staff members to follow when administering antipsychotic medications. Which standard is most important for the nurse-manager to include in this policy?

Correct Answer is B

Explanation

A client who is receiving antineoplastic chemotherapy has lost 25% of total body weight and is having difficulty eating because of stomatitis. In planning care for this client, which diet should the nurse recommend?

Correct Answer is C

Explanation

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