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 A
Explanation
Choice A reason: A 12-lead ECG can reveal changes in the ST segment, T wave, and QRS complex, which are indicative of myocardial ischemia, injury, or infarction. It is the first line diagnostic test that needs to be recorded within 10 minutes after the first medical contact in cases of suspected acute coronary syndromes.
Choice B reason: While pain radiating to the left arm can be a symptom of MI, it is not a definitive diagnostic action. It is a common symptom but can also be associated with other conditions.
Choice C reason: Checking the client's blood pressure is important in the overall assessment of the client's cardiovascular status but does not specifically diagnose MI. Blood pressure can be normal, elevated, or decreased in the case of MI.
Choice D reason: Auscultating heart tones can provide information about the presence of murmurs, gallops, or rubs, but it is not a specific diagnostic action for MI. Heart sounds may be normal during an MI.
Correct Answer is B
Explanation
Choice A reason:While sharing needles can transmit hepatitis, it is more commonly associated with hepatitis B and C, not hepatitis A.
Choice B reason:Eating shellfish from contaminated water is a well-known route of transmission for hepatitis A, aligning with the client's symptoms.
Choice C reason:Blood transfusions were a risk for hepatitis transmission in the past, but since the 1990s, blood products are screened for hepatitis, making this an unlikely source.
Choice D reason:Unprotected sex can be a route of transmission for hepatitis, but hepatitis A is more commonly spread through ingestion of contaminated food or water, not sexual contact.
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