A nurse in the recovery room is assessing a client who has a new chest tube. The nurse finds that the water seal is no longer tidaling. The nurse should identify the finding as resulting from which of the following?
An air leak noted at the insertion site.
The tubing may be kinked.
Water needs to be added to the suction-control chamber.
The suction is set too low.
The Correct Answer is B
A. An air leak noted at the insertion site would result in continuous bubbling in the water seal chamber, not the absence of tidaling.
B. If the tubing is kinked or obstructed, it can prevent the movement of air in and out of the water seal chamber, leading to the absence of tidaling.
C. If water needs to be added to the suction-control chamber, this would affect the level of suction, not the tidaling in the water seal chamber.
D. If the suction is set too low, it would not necessarily affect the tidaling in the water seal chamber; instead, it would result in inadequate drainage or lack of suction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
A. Visible contusions on all four extremities may indicate physical abuse, especially in the context of being brought to the emergency department by a family member. Reporting the
incident to Adult Protective Services is essential to ensure the safety and well-being of the client.
B. Interviewing the client with his adult child present may not be appropriate if there are concerns about potential abuse or coercion.
C. Forcing the client to answer every assessment question may not be appropriate if the client is in distress or unable to communicate freely.
D. Advising the client to consult a social worker may be appropriate, but reporting suspected abuse to Adult Protective Services is the priority action in this situation.
Correct Answer is B
Explanation
- A: An INR of 1.1 is within the normal range, indicating normal blood clotting ability, which is essential for wound healing. A normal INR does not pose a risk for delayed wound healing.
- B: Hyperemesis can lead to dehydration and malnutrition, both of which are detrimental to wound healing. Dehydration reduces blood volume and flow, impairing the delivery of oxygen and nutrients to the wound site, while malnutrition can weaken the immune response and the formation of new tissue.
- C: An HbA1C level of 5.6% is at the high end of the normal range and does not typically indicate diabetes or impaired glucose control, which are risk factors for delayed wound healing.
- D: While uncontrolled pain can be a concern for patient comfort and may indirectly affect wound healing by reducing mobility, it is not a direct risk factor for delayed wound healing like hyperemesis is.
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