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 B
Explanation
A. Cannabis withdrawal typically presents with symptoms such as irritability, anxiety, insomnia, decreased appetite, and physical discomfort, but not constricted pupils, delayed reflexes, and decreased blood pressure.
B. Opioid intoxication can cause constricted pupils (miosis), delayed reflexes, and decreased blood pressure, among other symptoms such as respiratory depression, drowsiness, and altered mental status.
C. Amphetamine intoxication typically presents with symptoms such as dilated pupils, increased blood pressure, tachycardia, agitation, and hallucinations, but not constricted pupils, delayed reflexes, and decreased blood pressure.
D. Alcohol withdrawal typically presents with symptoms such as tremors, anxiety, agitation, hallucinations, increased heart rate and blood pressure, but not constricted pupils, delayed reflexes, and decreased blood pressure.
Correct Answer is C
Explanation
A. Varicella-zoster (chickenpox) requires airborne precautions due to its transmission via respiratory droplets or aerosols.
B. Vancomycin-resistant enterococcus (VRE) is typically transmitted through direct contact with contaminated surfaces or equipment and does not require droplet precautions.
C. Pertussis (whooping cough) is transmitted via respiratory droplets and requires droplet precautions to prevent transmission to others.
D. Rotavirus is primarily transmitted through the fecal-oral route and requires contact precautions, not droplet precautions.
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