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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Beef liver - Beef liver is high in cholesterol and should be limited in the diet of someone with increased cholesterol levels.

B. Egg whites - Egg whites are low in cholesterol and can be a good source of protein for someone with increased cholesterol levels. It's the yolk of the egg that contains most of the cholesterol, so recommending egg whites is a good choice.

C. Steamed clams - Clams are low in cholesterol, but they are high in sodium, which may not be recommended for someone with increased cholesterol levels, depending on their overall dietary needs.

D. Broiled lobster - Lobster is high in cholesterol and should be limited in the diet of someone with increased cholesterol levels.

A. A client who has chronic obstructive pulmonary disease and needs guidance on incentive spirometry B. A client who had a myocardial infarction 3 days ago and reports chest discomfort C. A client who had a stroke 2 days ago and needs help toileting D. A client who has awoken following a bronchoscopy and requests a drink

Correct Answer is C

Explanation

A. Providing guidance on incentive spirometry requires specialized knowledge and skill that should be provided by a licensed healthcare provider, such as a nurse.

B. A client who had a myocardial infarction 3 days ago and reports chest discomfort requires ongoing assessment and monitoring by a licensed healthcare provider, such as a nurse, due to the potential for cardiac complications.

C. Assisting a client who had a stroke 2 days ago and needs help toileting is a task that can be safely delegated to an assistive personnel, as long as the client's condition is stable and the assistive personnel has been trained in providing basic care.

D. Providing a drink to a client who has awoken following a bronchoscopy may require assessment and monitoring for potential complications, such as aspiration or respiratory distress, which should be provided by a licensed healthcare provider, such as a nurse.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Naxlex Comprehensive Predictor Exams

A nurse is providing dietary teaching to a client who has an increased cholesterol level.Which of the following foods should the nurse recommend?

Correct Answer is B

Explanation

A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an assistive personnel?

Correct Answer is C

Explanation

A nurse in a pediatric unit is caring for a group of clients. For which of the following diseases should the nurse implement droplet precautions?

A nurse is assessing a client's cardiovascular system. Identify where the nurse should place the diaphragm of the stethoscope to best hear the closing of the aortic heart valve. (You will find "Hot Spots" to select in the artwork below. Select only the hotspot that corresponds to your answer.)

A nurse is evaluating the allergy profile of a client who has Graves' disease and is to undergo a thyroid scan. The nurse should identify which of the following allergies as a contraindication for the client to undergo a thyroid scan?

A nurse is preparing to administer eye drops to a client. Which of the following nursing actions is appropriate?

A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first?

A nurse is teaching a group of farmworkers who work with pesticides about minimizing exposure. Which of the following information should the nurse include in the teaching?

A nurse is caring for a client who reports the use of chondroitin and glucosamine. The health benefit of this supplement combination is to do which of the following?

A nurse is providing postoperative teaching to a client who has a newly inserted pacemaker.Which of the following statements by the client Indicates that the teaching has been effective?