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

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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Correct Answer is C

Explanation

A. There is no known significant interaction between garlic supplements and antidepressants.

B. There is no evidence to suggest that garlic supplements are contraindicated for individuals with a history of seizure disorders. Garlic is not known to exacerbate seizure activity or interact with anticonvulsant medications.
C. Garlic has antiplatelet properties, which can increase the risk of bleeding, especially when combined with other blood-thinning agents like aspirin. Clients who take aspirin daily are at an increased risk of bleeding complications if they also take garlic supplements. This makes it a contraindication in such cases.
D. There are no known contraindications specifically related to rheumatoid arthritis and garlic supplements.

A. A client who has gastroenteritis and is lethargic and confused B. A client who has cystic fibrosis, has a thick, productive cough, and reports thirst C. A client who has sickle cell anemia and reports pain 15 minutes after receiving oral analgesic D. A client who has diabetes mellitus and has a morning fasting capillary glucose of 185 mg/dL

Correct Answer is A

Explanation

A. Gastroenteritis can lead to dehydration and electrolyte imbalances, which can cause lethargy and confusion. This indicates a potentially serious condition requiring immediate attention.

B. While cystic fibrosis requires management, the symptoms described (thick, productive cough and thirst) are not immediately life-threatening.

C. Sickle cell anemia pain is significant but may not require immediate intervention if the client has just received analgesia and is being monitored.

D. While a morning fasting capillary glucose of 185 mg/dL is elevated in a client with diabetes mellitus, it does not require immediate intervention unless accompanied by symptoms of hyperglycemia such as confusion or lethargy.

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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?

Nursing Test Bank

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