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 ["69"]
Explanation
Convert the weight from pounds to kilograms
190 lb * (1 kg / 2.2046 lb) = 86.183 kg (rounded to three decimal places)
The recommended dietary allowance (RDA) of protein:86.183 kg * 0.8 g/kg = 68.946 g/day
Rounding to the nearest whole number, the client should receive approximately 69 grams of protein daily.
Correct Answer is C
Explanation
C. The vestibulocochlear nerve is responsible for both the vestibular function and the cochlear function. Impaired function of the vestibulocochlear nerve could result in symptoms related to vestibular dysfunction, such as disequilibrium (feeling unsteady or off balance) especially with movement.
A. The olfactory nerve (cranial nerve I) is responsible for the sense of smell.
B. Loss of peripheral vision is typically associated with impairment of the optic nerve (cranial nerve II), which is responsible for vision.
D. Deviation of the tongue occurs in injury to the hypoglossal nerve.
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