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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This response acknowledges the client's fear and invites them to express their concerns, allowing the nurse to address them effectively and provide necessary information or support.
A. This response focuses specifically on the fear of needles and may not address the client's overall apprehension about the procedure or their specific concerns.
C. This response directly asks the client to articulate their fears, which can help the nurse understand the specific reasons behind their anxiety and tailor their support and education accordingly.
D. While this response attempts to offer reassurance, it may come across as dismissive of the client's current fears and may not effectively address their concerns or provide the support they need before undergoing the procedure.
Correct Answer is D
Explanation
Muscle twitching can a feature of hypocalcemia which may eventually lead to tetany. It is therefore, necessary to report muscle twitching to avoid serious complications such as bronchospasm.
A. Neck stiffness is anticipated due to manipulation of neck muscles during surgery.
B. Hoarseness occurs due to injury of recurrent laryngeal nerve or manipulation of the vocal cords and surrounding structures during surgery.
C. Some drainage from the incision site is expected after surgery, including a total thyroidectomy
D. Muscle twitching may indicate neuromuscular irritability or electrolyte imbalances, which could be unrelated to the thyroidectomy surgery.
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