A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client’s lung has expanded?
No fluctuations in the water seal chamber
No reports of pleuritic chest pain
Occasional bubbling in the water seal chamber
Oxygen saturation of 95%
The Correct Answer is A
Choice A reason: No fluctuations in the water seal chamber. This finding indicates that the lung has expanded and there is no more air leaking from the pleural space. Fluctuations in the water seal chamber are normal when the client breathes, but they should stop when the lung is fully expanded.
Choice B reason: No reports of pleuritic chest pain. This finding does not indicate that the lung has expanded, as pleuritic chest pain can be caused by other factors, such as inflammation or infection of the pleura. Pleuritic chest pain is a sharp pain that worsens with breathing or coughing.
Choice C reason: Occasional bubbling in the water seal chamber. This finding does not indicate that the lung has expanded, as occasional bubbling can be normal or due to a small air leak. Continuous bubbling, however, indicates a large air leak and requires immediate attention.
Choice D reason: Oxygen saturation of 95%. This finding does not indicate that the lung has expanded, as oxygen saturation can be normal or high even with a collapsed lung. Oxygen saturation is the percentage of hemoglobin that is bound to oxygen in the blood.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Droplet precautions are not appropriate for a client who has tuberculosis and a productive cough. Droplet precautions are used to prevent the transmission of infectious agents that are spread by large respiratory droplets, such as influenza, pertussis, or meningitis. Droplet precautions require the use of a surgical mask, eye protection, and gloves when in close contact with the client.
Choice B reason: Protective precautions are not applicable for a client who has tuberculosis and a productive cough. Protective precautions are used to protect immunocompromised clients from exposure to pathogens, such as those undergoing chemotherapy, organ transplantation, or stem cell transplantation. Protective precautions require the use of a HEPA filter, a positive pressure room, and a mask for the client when leaving the room.
Choice C reason: Contact precautions are not sufficient for a client who has tuberculosis and a productive cough. Contact precautions are used to prevent the transmission of infectious agents that are spread by direct or indirect contact with the client or the client's environment, such as Clostridioides difficile, MRSA, or VRE. Contact precautions require the use of gloves and gowns when entering the room and the dedicated use of noncritical patientcare equipment.
Choice D reason: Airborne precautions are the correct type of isolation precautions for a client who has tuberculosis and a productive cough. Airborne precautions are used to prevent the transmission of infectious agents that are spread by small respiratory droplets that can remain suspended in the air, such as tuberculosis, measles, or chickenpox. Airborne precautions require the use of a respirator, such as an N95 mask, a negative pressure room, and a mask for the client when leaving the room.
Correct Answer is B
Explanation
Choice A reason: The client is unable to make vocal sounds. This conclusion is not based on the GCS score of 5 for best verbal response, which indicates that the client is oriented and converses normally. The client may have other reasons for being unable to make vocal sounds, such as intubation or injury to the vocal cords.
Choice B reason: The client opens his eyes when spoken to. This conclusion is based on the GCS score of 3 for eye opening, which indicates that the client responds to verbal stimuli. This is the highest level of eye opening response on the GCS.
Choice C reason: The client is unconscious. This conclusion is not based on the GCS score of 13 (3+5+5), which indicates that the client has a mild level of impaired consciousness. The client is not unconscious, but may have reduced awareness or attention.
Choice D reason: The client can follow simple motor commands. This conclusion is not based on the GCS score of 5 for best motor response, which indicates that the client localizes pain. This means that the client moves their limbs away from a painful stimulus, but does not necessarily follow commands.
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