A nurse is caring for a client who has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?
Occasional bubbling in the water-seal chamber
No reports of pleuritic chest pain
No tidaling in the water-seal chamber
Oxygen saturation of 95%
The Correct Answer is C
Choice A reason: Occasional bubbling in the water-seal chamber can indicate an air leak, which is not necessarily a sign of lung re-expansion. It could suggest that the lung has not fully re-expanded or that there is a persistent air leak.
Choice B reason: While the absence of pleuritic chest pain is a positive sign, it is not a definitive indicator of lung re-expansion. Pleuritic chest pain can subside even if the lung has not fully re-expanded.
Choice C reason: No tidaling in the water-seal chamber is a strong indicator that the lung has re-expanded. When the lung is fully expanded, it presses against the chest wall, eliminating the space where air could collect and thus stopping the water level from fluctuating with respiration.
Choice D reason: An oxygen saturation of 95% is within normal limits and suggests adequate oxygenation, but it does not specifically indicate lung re-expansion. Oxygen saturation can be maintained with supplemental oxygen or other supportive measures even if the lung has not fully re-expanded.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
A headache is not typically an indication of an allergy to nitroglycerin. Allergic reactions are more likely to present with symptoms such as rash, itching, or difficulty breathing.
Choice B reason:Headaches are a well-known side effect of nitroglycerin, due to its vasodilating effects, which can cause dilation of cerebral arteries.
Choice C reason:While anxiety can cause headaches, in this context, where the client has taken nitroglycerin, it is more likely that the headache is a side effect of the medication rather than anxiety.
Choice D reason:Tolerance to medication would reduce the effectiveness of the drug, not typically cause a headache. The headache is a common side effect, not an indication of tolerance.
Correct Answer is C
Explanation
Choice A reason: A client who works in a child care center is not typically at risk for hepatitis C unless they are exposed to blood or bodily fluids from an infected individual. Hepatitis C is primarily spread through blood-to-blood contact. While working in a child care center may increase the risk of exposure to various infections due to close contact with children, it is not a common route of transmission for hepatitis C.
Choice B reason: Eating raw shellfish is more commonly associated with hepatitis A and E, which are transmitted through the fecal-oral route, often due to contaminated food or water. Hepatitis C, however, is not typically transmitted through food or water. It is a bloodborne virus, and thus, eating raw shellfish would not be considered a high-risk activity for contracting hepatitis C.
Choice C reason: A client who has multiple tattoos is at risk for developing hepatitis C, particularly if the tattoos were done using non-sterile equipment or in an unregulated setting. The hepatitis C virus can be transmitted through the use of contaminated needles, which can occur in tattoo parlors that do not adhere to strict hygiene and sterilization practices. This is why choice C is the correct answer. While all the options presented could potentially involve some risk of infection, it is the client with multiple tattoos who is most at risk for hepatitis C, assuming the tattoos were obtained in a setting where infection control practices were not followed. It’s important for healthcare providers to assess each client’s individual risk factors and educate them on the ways to prevent hepatitis C, such as ensuring the use of sterile needles for tattoos and piercings.
Choice D reason: Traveling to an underdeveloped country may increase the risk of various infectious diseases, but hepatitis C is not commonly spread through casual contact or environmental factors. It requires blood-to-blood contact for transmission. Therefore, unless the client engaged in activities that involved such exposure, like receiving medical or dental procedures with non-sterile equipment, simply traveling to an underdeveloped country does not significantly increase the risk of contracting hepatitis C.
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