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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Choice A: Flavored gelatin can be a choice if the client enjoys it, but it should not be the primary source of nutrition as it lacks protein and other essential nutrients needed for healing.
Choice B: Eggs are a good source of protein, which is essential for tissue repair and healing.
Choice C: Soda crackers are low in protein and do not provide adequate nutrition for postoperative healing.
Choice D: Baked chicken is a lean source of protein and can be a part of a balanced postoperative diet.
Choice E: Salmon is rich in omega-3 fatty acids and protein, which can support the healing process and provide essential nutrients.
Correct Answer is B
Explanation
Choice A: Pretzels are a carbohydrate-rich snack with a high glycemic index, which can lead to spikes in blood glucose levels. Choosing pretzels does not indicate a good understanding of the diet teaching to avoid refined sugar and carbohydrates.
Choice B: Avocado is a healthy choice for a client with Type 2 diabetes mellitus (DM) who wants to avoid refined sugar and carbohydrates. Avocado is a source of healthy fats, fiber, and other nutrients and has a low glycemic index.
Choice C: Potatoes are starchy vegetables that are high in carbohydrates, particularly when prepared in ways like mashed potatoes or fries. Choosing potatoes does not align with the goal of avoiding refined sugar and carbohydrates.
Choice D: Grapes are a fruit that contains natural sugars, and consuming them can affect blood glucose levels. Choosing grapes does not demonstrate an understanding of the need to avoid refined sugar and carbohydrates.
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