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. Art therapist: Art therapy can provide a nonverbal outlet for expressing feelings and emotions, which can be particularly beneficial for clients with schizophrenia who may struggle with verbal communication.
B. Speech-language pathologist: While speech-language pathologists may assist with communication difficulties, their expertise is more focused on speech and language disorders rather than addressing emotional expression in clients with schizophrenia.
C. Social worker: Social workers provide support and assistance with various psychosocial
issues, but they may not specifically address the client's difficulty expressing feelings through therapeutic interventions like art therapy.
D. Recreational therapist: Recreational therapy focuses on promoting leisure and recreational
activities to improve overall well-being, but it may not directly address the client's difficulty with emotional expression.
Correct Answer is A
Explanation
A.
A. Edema is a common early sign of compartment syndrome as increased pressure within the compartment impairs venous outflow, leading to swelling.
B. Shortness of breath is not typically associated with compartment syndrome but may indicate other respiratory or cardiac issues.
C. Petechiae are not typically associated with compartment syndrome but may occur in conditions such as thrombocytopenia or coagulopathy.
D. Change in mental status is not typically associated with compartment syndrome but may indicate other neurological issues.
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