A nurse is caring for a client following the placement of a chest tube drainage system for a pneumothorax. Which of the following findings should the nurse expect?

Serous drainage noted in the collection chamber

Tidaling in the water seal chamber with respirations

Diminished breath sounds in the lung bases

Movement of the trachea toward the unaffected side

Answer and Explanation

The Correct Answer is B

A. Serous drainage noted in the collection chamber: The type of drainage typically seen with a pneumothorax is not serous; it is usually minimal or absent. If there is significant drainage, it could indicate bleeding or another issue that should be monitored.

B. Tidaling in the water seal chamber with respirations: Tidaling, or the movement of the water level in the water seal chamber with respirations, is a normal finding. It indicates that the chest tube is correctly placed, and the lung is expanding and contracting.

C. Diminished breath sounds in the lung bases: Diminished breath sounds are expected in the area where the pneumothorax occurred, but it does not specifically indicate the placement of the chest tube.

D. Movement of the trachea toward the unaffected side: Tracheal deviation toward the unaffected side is a sign of tension pneumothorax, which is a medical emergency. It should not be expected following the placement of a chest tube for a pneumothorax, as the goal of the chest tube is to resolve the pneumothorax and prevent complications.

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Correct Answer is ["C","D","E"]

Explanation

A. Born with a high birth weight: High birth weight is generally not considered a risk factor for hearing loss. In fact, low birth weight, prematurity, or complications during birth are more often associated with an increased risk of hearing issues.

B. Frequent exposure to low-volume noise: Frequent exposure to low-volume noise is not typically a risk factor for hearing loss. However, exposure to loud noises (high volume) over time is a significant risk factor for hearing damage and loss.

C. Use of a loop diuretic: The use of loop diuretics, such as furosemide, is associated with an increased risk of ototoxicity, which can lead to hearing loss. This is a known risk for people taking these medications, especially in high doses or with prolonged use.

D. Chronic infections of the middle ear: Chronic ear infections can lead to hearing loss by damaging the structures of the middle ear or causing scarring. Recurrent middle ear infections, or otitis media, increase the risk of long-term hearing impairment.

E. Perforation of the eardrum: A perforated eardrum can lead to hearing loss, particularly if it affects the middle ear's ability to transmit sound properly. It can also make the ear more susceptible to infections, which could further contribute to hearing loss.

A. Oral temperature 37.8° C (100 F) B. Client can wiggle their toes C. Feet warm to the touch D. Pedal pulses +1

Correct Answer is D

Explanation

A. Oral temperature 37.8° C (100.0° F): A mild fever (37.8° C) could be a normal response to trauma or stress, especially following casting. It does not necessarily indicate an urgent issue, but it should be monitored, particularly if it increases or persists.
B. Client can wiggle their toes: The ability to move the toes is a positive sign that the neurovascular function of the extremities is intact. This is reassuring and indicates that circulation and nerve function are being maintained.
C. Feet warm to the touch: Warm feet suggest that there is adequate blood circulation to the extremities. This is a positive finding and does not require intervention unless other signs of complications arise.
D. Pedal pulses +1: A +1 pulse indicates weak pulses, which is concerning after casting. It may be a sign of reduced circulation, and the nurse should assess for further complications such as compartment syndrome, which can result in inadequate blood flow and tissue damage.

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A nurse is caring for a client following the placement of a chest tube drainage system for a pneumothorax. Which of the following findings should the nurse expect?

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