A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?
1 cm of water present in the water seal chamber
Tidaling with spontaneous respirations
Suction chamber pressure of -20 cm H20
Drainage collection chamber is one-third full
The Correct Answer is A
A. The water seal chamber should contain at least 2 cm of water to maintain the seal and prevent air from entering the pleural space. Only 1 cm of water is inadequate and requires intervention.
B. Tidaling, or fluctuation of water with respirations, is an expected finding and indicates that the system is functioning properly.
C. A suction chamber pressure of -20 cm H₂O is the standard setting for chest tube drainage systems and does not require intervention.
D. A drainage collection chamber that is one-third full is within normal limits and simply indicates the need to continue monitoring output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
A. A BMI of 20 falls within the healthy weight range for adults, indicating that the client's weight is appropriate for his height.
B. A BMI of 20 is not indicative of malnutrition. Malnutrition is typically associated with lower BMIs.
C. A BMI of 20 is not within the overweight range, as overweight is typically defined as a BMI between 25 and 29.9.
D. A BMI of 20 is not within the obesity range, as obesity is typically defined as a BMI of 30 or higher.
Correct Answer is D
Explanation
A. Povidone-iodine may be used as a wound cleanser, but the method described here (using cotton balls) is not typically recommended as it can leave fibers in the wound.
B. Administering oral analgesia prior to wound irrigation may be appropriate for pain management but is not directly related to understanding wound irrigation technique.
C. Warming irrigation solution in a microwave oven can lead to uneven heating and potential tissue damage. This method is not recommended for warming irrigation solution.
D. Irrigating the wound from the top to the bottom ensures that contaminants are flushed away from the wound site, reducing the risk of infection and promoting healing. This indicates an understanding of proper wound irrigation technique.
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