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%

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Turning on the television for the client during meals is not a good idea, as it can distract the client from eating and swallowing properly, and increase the risk of choking or aspiration.

Choice B reason: Providing the client with oral hygiene is important, but it is not enough to prevent aspiration pneumonia. Oral hygiene can reduce the amount of bacteria in the mouth, but it does not prevent food or liquid from entering the airways.

Choice C reason: Elevating the head of the client’s bed to 45 degrees during meals is the best action to prevent aspiration pneumonia, as it helps the client swallow more easily and reduces the chance of food or liquid going into the lungs.

Choice D reason: Instructing the client to tilt their head back while swallowing is a dangerous action, as it can actually increase the risk of aspiration pneumonia. Tilting the head back can open the airway and allow food or liquid to enter the lungs instead of the esophagus.

A. "I will be able to tell how much oxygen I'm getting by looking at the flowmeter." B. "I should call my doctor if I find it harder to concentrate." C. "I will wear synthetic clothing and woolen socks when using my oxygen." D. "I will make sure my visitors smoke outside."

Correct Answer is C

Explanation

Choice A reason: "I will be able to tell how much oxygen I'm getting by looking at the flowmeter." This statement is correct because the flowmeter shows the amount of oxygen delivered in liters per minute. The client should check the flowmeter regularly and adjust it according to the prescription.

Choice B reason: "I should call my doctor if I find it harder to concentrate." This statement is correct because difficulty concentrating can be a sign of low oxygen levels or carbon dioxide retention. The client should monitor their symptoms and report any changes to their doctor.

Choice C reason: "I will wear synthetic clothing and woolen socks when using my oxygen." This statement is incorrect because synthetic clothing and woolen socks can create static electricity and increase the risk of fire when using oxygen. The client should wear cotton clothing and avoid materials that can cause sparks.

Choice D reason: "I will make sure my visitors smoke outside." This statement is correct because smoking near oxygen can cause a fire or explosion. The client should keep oxygen away from open flames, smoking materials, and heat sources.

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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?

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