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A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?

A.

1 cm of water present in the water seal chamber

B.

Tidaling with spontaneous respirations

C.

Suction chamber pressure of -20 cm H20

D.

Drainage collection chamber is one-third full

Answer and Explanation

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.


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Related Questions

Correct Answer is B

Explanation

A. A fundal height of 2 fingerbreadths below the umbilicus in a client who is 2 days postpartum is within the expected range for that time frame and does not require immediate assessment.

B. A client who is 1 day postpartum and has not voided in 8 hours may be at risk for urinary retention, which can lead to complications such as bladder distension or urinary tract infection. Prompt assessment and intervention are needed.

C. Not having a bowel movement since prior to admission is not an urgent concern in the

immediate postpartum period, especially if the client is otherwise stable and not experiencing discomfort or other symptoms.

D. Lochia serosa, which is the normal vaginal discharge that occurs 3 to 10 days postpartum, is not an urgent concern and does not require immediate assessment.

Correct Answer is D

Explanation

A. Chondroitin and glucosamine are not typically used to treat depression.

B. While some supplements may support immune health, chondroitin and glucosamine are primarily used to support joint health, not immune function.

C. Chondroitin and glucosamine are not indicated for the prevention or treatment of prostate enlargement.

D. Chondroitin and glucosamine are commonly used supplements for managing symptoms of osteoarthritis and improving joint health by supporting cartilage repair and reducing

inflammation.

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