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","B","C","D","E"]
Explanation
Choice A reason: Pain occurring 30 to 60 minutes after a meal is a common symptom of gastric ulcers due to the increased gastric acid secretion during digestion that can aggravate the ulcer.
Choice B reason: Pain at night is also typical for gastric ulcers as the circadian rhythm can influence acid secretion, potentially leading to increased discomfort during the night.
Choice C reason: A sensation of bloating can be associated with gastric ulcers due to delayed gastric emptying or increased sensitivity of the stomach lining.
Choice D reason:Pain relieved by eating is indicative of gastric ulcers because food can act as a buffer to stomach acid, temporarily relieving pain².
Choice E reason:Pain upon palpation of the epigastric region is expected in clients with gastric ulcers due to the localized inflammation and sensitivity of the stomach lining².
Correct Answer is B
Explanation
Choice A reason: Heparin and warfarin do not work together to dissolve clots. Heparin acts quickly to prevent further clotting, while warfarin is used for long-term anticoagulation.
Choice B reason: Warfarin's onset of action is slow, requiring several days to reach therapeutic levels. During this time, heparin is used to provide immediate anticoagulation to prevent new clot formation or the growth of existing clots.
Choice C reason: IV heparin does not increase the effects of warfarin. They are used concurrently because of the delay in warfarin's onset of action.
Choice D reason: It is not appropriate to discontinue heparin immediately after starting warfarin due to the delay in warfarin reaching therapeutic levels. The overlap is necessary to ensure continuous anticoagulation.
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