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 D
Explanation
Choice A: Milk products, canned salmon, and fresh oysters are sources of calcium and may be included in the diet but are not primary sources of potassium.
Choice B: Cranberry juice, butter, and hard candy are not significant sources of potassium and may not address the client's hypokalemia.
Choice C: Hard cheese, whole-grain cereals, and dried vegetables are not primary sources of potassium and may not provide an adequate potassium intake.
Choice D: Potatoes, bananas, and oranges are all good dietary sources of potassium and should be encouraged for a client with hypokalemia. Increasing potassium-rich foods can help correct low potassium levels.
Correct Answer is B
Explanation
Choice A: Sweaty palms may be related to various factors, including anxiety, physical activity, or environmental conditions. While it may warrant further assessment, it is not necessarily indicative of a nutritional issue in a professional dancer.
Choice B: Fatigue in a professional dancer can be a concerning issue and may indicate an underlying nutritional problem, such as inadequate calorie intake or nutrient deficiencies. Further assessment of the client's dietary habits and energy levels is warranted.
Choice C: Bunions are a foot deformity and are not directly related to nutritional assessment.
Choice D: Dry skin may be related to various factors, including environmental conditions and skin care practices. It may warrant assessment but is not necessarily indicative of a nutritional issue.
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