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 ["<p>Client urinating 100 mL\/hour. Client is tolerating soft diet and oral fluids<\/p>\r\n\r\n<p>Bilateral pedal pulses 2+. Blood glucose 310 mg\/dL (74 to 106 mg\/dL)<\/p>\r\n\r\n<p>Pulse rate 84\/min<\/p>\r\n\r\n<p>Blood pressure 106\/76 mm Hg<\/p>"]

Explanation

The frequency and amount of urination indicates that the body in able to utilize glucose reducing glucosuria and osmotic diuresis.

The ability to tolerate oral intake also indicates an improvement in the client’s general health

Improvement in perception of pedal pulses indicates an improvement in the hydration status of the client

A normal pulse rate and blood pressure is an indicator of optimal hydration status- an improvement from the severely dehydrated state.

The blood glucose levels is dropping indicating an improvement in the glycemic control

A. Dextrose 5% in water (DSW) intravenous at 5 ml/kg/hr for 4 hr B. Potassium chloride 20 mEq/L intravenous PRN potassium less than 5.0 mEq/L C. Regular insulin continuous intravenous infusion, titrate per diabetic ketoacidosis (DKA) protocol once potassium is greater than 3.3 mEq/L D. Regular insulin 20 units subcutaneously E. Blood glucose checks every 4 hr F. Initiate cardiac monitoring G. Insert indwelling urinary catheter H. 0.9% sodium chloride at 15 ml/kg/hr for 1 hr and then reduce to 10 ml/kg/hr

Correct Answer is ["B","C","F","H"]

Explanation

The client has diabetes ketoacidosis (DKA) as seen in the lab findings. The management of DKA involves fluid rehydration with isotonic crystalloids such as normal saline, glycemic control with intravenous insulin infusion and electrolyte supplementation specifically potassium if it is normal or low.

This is because administration of insulin drives potassium ions into the cells leading to hypokalemia Cardiac monitoring is vital to ensure that any dysrhythmias due to electrolyte disturbances are recognized early.

Blood sugar monitoring should be done more frequently- preferably every 1 hour. Although monitoring of output is key, catheterization is unnecessary when the client is awake.

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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

Correct Answer is ["<p>Client urinating 100 mL\/hour. Client is tolerating soft diet and oral fluids<\/p>\r\n\r\n<p>Bilateral pedal pulses 2+. Blood glucose 310 mg\/dL (74 to 106 mg\/dL)<\/p>\r\n\r\n<p>Pulse rate 84\/min<\/p>\r\n\r\n<p>Blood pressure 106\/76 mm Hg<\/p>"]

Explanation

A nurse is caring for a client in the emergency department. Exhibits Which of the following 3 provider prescriptions does the nurse anticipate?

Correct Answer is ["B","C","F","H"]

Explanation

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