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: The older female client who had a hip replacement yesterday and is notably pale with a hemoglobin of 10.5 g/dl likely needs attention, but the information provided does not indicate an urgent, life-threatening situation. Immediate intervention may not be necessary based on the information given.

Choice B: The adult client with osteomyelitis of the ankle who refuses an IV restart for antibiotics is concerning, but it does not represent an immediate life- threatening situation. The client's refusal should be addressed, but it may not require immediate attention.

Choice C: The elderly client with low back pain who removed pelvic traction and wants to go home may require assessment and intervention, but the information provided does not indicate an urgent, life-threatening situation. It may not be the first priority.

Choice D: The young adult client with a closed reduction of a fractured femur complaining of increasingly severe pain is the most concerning. Pain assessment and management are critical, and uncontrolled pain can lead to complications. This client should be attended to first to assess and address the pain.

A. Impaired cognition. B. Memory loss. C. Mood alterations. D. Hearing loss.

Correct Answer is C

Explanation

Choice A: Impaired cognition is not a common manifestation of Cushing's syndrome. Cushing's syndrome is primarily characterized by hormonal imbalances and physical symptoms.

Choice B: Memory loss is not a common manifestation of Cushing's syndrome. The syndrome is more associated with hormonal and metabolic disturbances.

Choice C: Mood alterations, including irritability, anger, and emotional instability, are common manifestations of Cushing's syndrome. These mood changes can be attributed to the hormonal imbalances and physiological stress associated with the condition.

Choice D: Hearing loss is not a recognized symptom of Cushing's syndrome. Mood alterations and physical changes are more typical.

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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?

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Naxlex Comprehensive Predictor Exams

After receiving morning report about four clients, which client should the nurse attend to first?

Correct Answer is D

Explanation

The practical nurse (PN) overhears a female client with Cushing's syndrome tell her family in a very loud and angry voice to leave her room and not to come back. The response by the PN is based on recognizing which common manifestation of the syndrome?

Correct Answer is C

Explanation

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