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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?

A.

Gentle bubbling in the water seal chamber

B.

Drainage and warmth at tube insertion site

C.

Crackling sensation felt around tube insertion site

D.

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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Related Questions

Correct Answer is B

Explanation

Restraints should be avoided whenever possible. Addressing the underlying cause of wandering (such as anxiety, discomfort, or confusion) is essential.
A. In cases where restraints are deemed necessary to prevent harm to the client, such as preventing them from dislodging their tube feeding, it may be appropriate.
C. The use of an abduction pillow is a common preventive measure to maintain proper hip alignment and prevent hip dislocation, especially after hip surgery.
D. Soft heel protectors are used to prevent pressure ulcers and protect the heels from injury while the client is in bed.

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"C"}}

Explanation

Alterations in level of consciousness is an indicator that the client is in septic shock due to systemic spread of the urinary tract infection

Hematocrit level is normal. Changes in hematocrit levels are not expected in UTI unless the client has hematuria.

A butterfly rash is commonly seen in autoimmune conditions like lupus.

The decrease in oxygen requirements indicates improvement in level of distress and hence improving sepsis

A drop in the systolic blood pressure may indicate that the client is going into septic shock

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