A nurse is caring for a client who has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication?
Continuous bubbling in the water-seal chamber
Occasional bubbling in the water-seal chamber
Fluctuations in the fluid level in the water-seal chamber
Constant bubbling in the suction-control chamber
The Correct Answer is A
Choice A Reason: Continuous bubbling in the water-seal chamber indicates an air leak in the chest tube system, which can compromise the drainage of air and fluid from the pleural space and impair lung expansion.
Choice B Reason: Occasional bubbling in the water-seal chamber is normal and expected, as it indicates that air is being removed from the pleural space.
Choice C Reason: Fluctuations in the fluid level in the water-seal chamber are normal and expected, as they reflect changes in intrathoracic pressure during inspiration and expiration.
Choice D Reason: Constant bubbling in the suction-control chamber is normal and expected, as it indicates that suction is being applied to the chest tube system.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: To calculate the total body surface area (TBSA) affected by burns using the Rule of Nines, the body is divided into sections, each representing a percentage of TBSA:
- Front of one leg = 9%
- Back of one leg = 9%
- Front of one arm = 4.5%
- Back of one arm = 4.5%
Now for the calculation:
-
Both legs (front and back):
- Front of both legs = 9% × 2 = 18%
- Back of both legs = 9% × 2 = 18%
- Total for both legs = 18% + 18% = 36%
-
Both arms (front and back):
- Front of both arms = 4.5% × 2 = 9%
- Back of both arms = 4.5% × 2 = 9%
- Total for both arms = 9% + 9% = 18%
-
Total TBSA:
- Legs (36%) + Arms (18%) = 54%
The nurse should document burns to 54% of the client's total body surface area (TBSA).
Choice B Reason:This choice is incorrect because it uses the original rule of nines for adults, not children. It also does not account for the depth and degree of the burns.
Choice C Reason: This choice is incorrect because it uses the original rule of nines for adults, not children. It also does not account for the depth and degree of the burns.
Choice D Reason: This choice is incorrect because it uses a random percentage that does not correspond to any rule or calculation.
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because administering a nitrate antihypertensive is not the first action, as it may cause a rapid drop in blood pressure and worsen the client's condition.
Choice B Reason: This is incorrect because obtaining the client's heart rate is not the first action, as it does not address the cause of autonomic dysreflexia or relieve the symptoms.
Choice C Reason: This is incorrect because assessing the client for bladder distention is not the first action, as it may take time and delay the treatment of autonomic dysreflexia.
Choice D Reason: This is correct because placing the client in a high-Fowler's position is the first action, as it lowers the blood pressure by promoting venous return and reducing cardiac preload.
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