A nurse is caring for a client following an insertion of a chest tube drainage system for a pneumothorax. Which of the following manifestations should the nurse expect the client to demonstrate?

Gentle bubbling in the water seal chamber

Drainage and warmth at tube insertion site

Crackling sensation felt around tube insertion site

Drainage output less than 70 mL/hr

Answer and Explanation

The Correct Answer is A

A.   Bubbling indicates that the system is functioning properly and that air is being evacuated from the pleural space.
B.   Drainage and warmth at the tube insertion site could indicate inflammation or infection, which are potential complications following insertion of a chest tube.
C.   Crackling sensation felt around tube insertion site could indicate subcutaneous emphysema, which occurs when air leaks into the tissues surrounding the chest tube insertion site. It's a potential complication of chest tube insertion and should be monitored closely

D.   The specific amount can vary.

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Correct Answer is C

Explanation

C. Placing pillows between the client's knees when in a side-lying position helps maintain proper alignment of the hips and prevents the affected leg from crossing over the midline, which could lead to muscle
contractures or discomfort. It also helps prevent pressure on bony prominences and reduces the risk of skin breakdown.
A. Keeping the bony prominences too moist could lead to increased risk of skin breakdown.
B. This is not recommended as it could exacerbate muscle weakness or discomfort on the affected side and may not provide adequate support for proper alignment.
D. Raising the head of the bed to a 90° angle is not typically indicated for clients with hemiplegia. It may increase the risk of aspiration

A. Blood glucose level B. Bowel sounds C. Blood pressure D. Pain level E. Electrocardiogram findings F. Lung sounds G. Troponin T level

Correct Answer is ["C","D","E","G"]

Explanation

The blood pressure is elevated. This may indicate a compensatory mechanism to try increases myocardial perfusion. However, this increases the oxygen demand worsening the condition.

Pain level of 7 indicates severe pain typical of acute coronary syndrome. The pain may worsen the extent of ischemia and hence morphine should be administered immediately

ECG findings are typical for myocardial infarction and intervention is key to prevent further myocardial damage.

Troponin levels are elevated due to damage of myocardium

Blood sugar level, bowel sounds and lung sounds are normal and therefore, requires no intervention.

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A nurse is caring for a client following an insertion of a chest tube drainage system for a pneumothorax. Which of the following manifestations should the nurse expect the client to demonstrate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has hemiplegia. Which of the following interventions should the nurse include?

Correct Answer is C

Explanation

A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Exhibits The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up.

Correct Answer is ["C","D","E","G"]

Explanation

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