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 B
Explanation
Choice A reason: Placing food on the weaker side of the mouth when eating is not an effective strategy for a client who has dysphagia. This can increase the risk of choking or aspiration, as the food may not be chewed properly or may slip into the airway. The client should place food on the stronger side of the mouth and use the tongue to move it to the back of the throat for swallowing.
Choice B reason: Tilting the head forward when swallowing is an effective technique for a client who has dysphagia. This can help to close off the airway and prevent food or liquid from entering the lungs. The client should also tuck the chin down to the chest and swallow hard.
Choice C reason: Coughing while swallowing food is not a desirable outcome for a client who has dysphagia. This can indicate that the food is going into the wrong pipe and causing irritation or obstruction. The client should try to avoid coughing while swallowing and clear the throat after each bite or sip.
Choice D reason: Sitting at a 30° angle while eating meals is not a sufficient position for a client who has dysphagia. This can still allow food or liquid to flow back into the throat and cause choking or aspiration. The client should sit upright at a 90° angle and remain in that position for at least 30 minutes after eating.
Correct Answer is C
Explanation
Choice A reason: This is incorrect. Right hemiparesis is not a common finding in clients who had a stroke involving the right hemisphere. Hemiparesis is the weakness or partial paralysis of one side of the body. It usually affects the opposite side of the body from the side of the brain that is damaged by the stroke. Therefore, a stroke in the right hemisphere would more likely cause left hemiparesis, not right hemiparesis.
Choice B reason: This is incorrect. Aphasia is not a common finding in clients who had a stroke involving the right hemisphere. Aphasia is the loss or impairment of language functions, such as speaking, understanding, reading, or writing. It usually affects the dominant hemisphere of the brain, which is the left hemisphere for most people. Therefore, a stroke in the right hemisphere would less likely cause aphasia, unless the person is lefthanded or ambidextrous.
Choice C reason: This is correct. Inability to recognize his family members is a common finding in clients who had a stroke involving the right hemisphere. This is a type of agnosia, which is the loss or impairment of the ability to recognize objects, people, sounds, shapes, or smells. The right hemisphere of the brain is responsible for processing visual and spatial information, as well as facial recognition. A stroke in this area can damage the ability to identify familiar faces, even those of close relatives or friends.
Choice D reason: This is incorrect. Difficulty reading is not a common finding in clients who had a stroke involving the right hemisphere. Reading is a language function that involves the recognition and comprehension of written words. It usually depends on the dominant hemisphere of the brain, which is the left hemisphere for most people. Therefore, a stroke in the right hemisphere would less likely cause difficulty reading, unless the person is lefthanded or ambidextrous.
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