A nurse is assessing a client who is 1 day postoperative following a lobectomy and has a chest tube drainage system in place. Which of the following findings by the nurse indicates a need for intervention?

Development of subcutaneous emphysema

Chest tube eyelets not visible

Continuous bubbling in the suction control chamber

Presence of tidal fluctuation in the water seal chamber

Answer and Explanation

The Correct Answer is A

The correct answer is: a. Development of subcutaneous emphysema

Choice A: Development of subcutaneous emphysema

Reason: Subcutaneous emphysema occurs when air gets trapped under the skin, often due to a leak from the lung or chest tube. This can indicate a serious complication such as a pneumothorax or a malfunctioning chest tube, requiring immediate medical intervention. The presence of subcutaneous emphysema can lead to discomfort, respiratory distress, and further complications if not addressed promptly.

Choice B: Chest tube eyelets not visible

Reason: The eyelets of a chest tube are small holes at the end of the tube that allow air and fluid to drain from the pleural space. These eyelets are typically covered by a dressing and may not be visible. This is not necessarily a cause for concern unless there are other signs of malfunction or complications.

Choice C: Continuous bubbling in the suction control chamber

Reason: Continuous bubbling in the suction control chamber is expected and indicates that the suction is functioning properly. It does not indicate a problem unless the bubbling is in the water seal chamber, which would suggest an air leak.

Choice D: Presence of tidal fluctuation in the water seal chamber

Reason: Tidal fluctuation, or tidaling, in the water seal chamber is a normal finding. It indicates that the chest tube is patent and functioning correctly, as the water level rises with inhalation and falls with exhalation. The absence of tidaling could indicate a blockage or that the lung has fully re-expanded.

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Correct Answer is C

Explanation

Choice A reason: "Use simple, childlike statements when speaking." This response is not appropriate because it can be demeaning and disrespectful to the client. The client is an adult who knows what they want to say, but they have difficulty saying it. Using simple statements is helpful, but they should not be childlike or patronizing.

Choice B reason: "Use a higher pitched tone of voice when speaking." This response is not appropriate because it can be irritating and confusing to the client. The client may have normal hearing, or they may have hearing loss due to age or stroke. Using a higher pitched tone of voice can make the speech harder to understand and may imply that the client is not intelligent.

Choice C reason: "Incorporate nonverbal cues in the conversation." This response is appropriate because nonverbal cues, such as gestures, facial expressions, and drawings, can help the client understand and express themselves better. Nonverbal cues can also reduce frustration and anxiety for both the client and the family member.

Choice D reason: "Ask multiple choice questions as part of the conversation." This response is not appropriate because it can be overwhelming and stressful for the client. Multiple choice questions can be hard to process and remember for someone with aphasia. It is better to ask yes or no questions, or to provide options with visual cues.

A. Oral mucosa B. Conjunctivae C. Ear lobes D. Soles of the feet

Correct Answer is A

Explanation

Choice A reason: The oral mucosa is the most reliable indicator of central cyanosis because it reflects the oxygen saturation of the arterial blood. Central cyanosis occurs when the arterial blood has a low oxygen saturation due to a cardiopulmonary problem. The oral mucosa is less affected by peripheral factors such as temperature, vasoconstriction, or skin pigmentation.

Choice B reason: The conjunctivae are not a reliable indicator of central cyanosis because they can be affected by other conditions such as anemia, jaundice, or eye infections. The conjunctivae are the thin membranes that cover the white part of the eye and the inner surface of the eyelids.

Choice C reason: The ear lobes are not a reliable indicator of central cyanosis because they can be affected by peripheral factors such as temperature, vasoconstriction, or skin pigmentation. The ear lobes are the fleshy lower part of the external ear.

Choice D reason: The soles of the feet are not a reliable indicator of central cyanosis because they can be affected by peripheral factors such as temperature, vasoconstriction, or skin pigmentation. The soles of the feet are the bottom part of the feet.

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