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 D

Explanation

Choice A: Performing a physical assessment of the newborn is important but should not be the first action when the infant is handed to the nurse during a cesarean delivery.

Choice B: Determining an APGAR score is important for assessing the newborn's overall condition, but allowing the mother to touch the infant should be the first action.

Choice C: Drying the infant under a warming unit is an important step to maintain the infant's body temperature, but allowing the mother to touch the infant should be prioritized first.

Choice D: Allowing the mother to touch the infant immediately after delivery is a crucial bonding and comforting moment for both the mother and the newborn. It should be the first action taken before other assessments or interventions.

A. Teach clients to be aware that dryness of the mouth can occur with the use of antipsychotic drugs. B. Monitor all clients receiving antipsychotic drugs for indications of tardive dyskinesia. C. Ensure that all clients treated with antipsychotic drugs receive prompt renewals as needed. D. Document all client therapeutic serum levels that relate to antipsychotic medications.

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.

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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 healthcare provider hands a newborn to the circulating nurse during a cesarean delivery. What action should the nurse implement first?

Correct Answer is D

Explanation

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

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