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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Obtaining an electrocardiogram (ECG) is the first action to take when managing a client with an electrical shock injury. Electrical shock injuries can cause cardiac dysrhythmias, including ventricular fibrillation or other life-threatening arrhythmias. Therefore, obtaining an ECG allows for prompt assessment of cardiac rhythm and identification of any dysrhythmias that may require immediate intervention.
A. While fluid resuscitation may be necessary in the management of electrical shock injuries to address hypovolemia and promote renal perfusion, titrating IV fluids to maintain a specific urine output is not the first action to take.
B. Pain management is important in the care of clients with electrical shock injuries, but it is not the first action to prioritize
C. Changing dressings over the entrance and exit wounds is important for wound care, but it is not the first action to take.
Correct Answer is B
Explanation
B. The client's PPD skin test result of 12 mm induration is considered positive for individuals who are at increased risk of tuberculosis, such as those with recent exposure to tuberculosis or immunocompromised individuals. A positive PPD result typically requires follow-up with a healthcare provider for further evaluation, which may include chest X-rays, sputum cultures, and treatment for latent tuberculosis infection if indicated.
A. Annual PPD testing may be indicated for certain populations, such as healthcare workers or individuals at high risk of exposure to tuberculosis. However, the decision to repeat the PPD test annually should be based on individual risk factors and healthcare provider recommendations.
C. The PPD skin test is typically read 48-72 hours after administration to assess for induration.
D. A PPD skin test result of 12 mm induration is considered positive for individuals at increased risk of tuberculosis, but it does not necessarily indicate that the test needs to be repeated immediately.
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