A nurse is caring for a client who is 12 hours postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations?

Constant bubbling in the suction-control chamber.

Bloody drainage in the collection chamber.

Fluid-level fluctuations in the water-seal chamber.

Continuous bubbling in the water-seal chamber.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Constant bubbling in the suction-control chamber is expected and indicates that the suction is functioning properly.
Choice B rationale
Bloody drainage in the collection chamber is expected in the immediate postoperative period and does not require intervention.
Choice C rationale
Fluid-level fluctuations in the water-seal chamber are normal and indicate that the system is functioning properly.
Choice D rationale
Continuous bubbling in the water-seal chamber indicates an air leak and requires intervention to prevent complications.

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Correct Answer is B

Explanation

Choice A rationale
Fever. This statement is incorrect. While fever can occur in clients with ITP due to infections, it is not a specific manifestation of the condition. ITP primarily affects platelet counts and bleeding tendencies.
Choice B rationale
Ecchymosis. This statement is correct. Ecchymosis, or bruising, is a hallmark manifestation of ITP due to low platelet counts and increased bleeding tendencies. Clients with ITP are prone to bruising and bleeding even with minor trauma.
Choice C rationale
Fatigue. This statement is incorrect. While fatigue can occur in clients with ITP due to anemia or chronic illness, it is not a specific manifestation of the condition. ITP primarily affects platelet counts and bleeding tendencies.
Choice D rationale
Elevated WBC. This statement is incorrect. Elevated white blood cell counts are not typically associated with ITP, which primarily affects platelet counts. An elevated WBC may indicate infection or inflammation but is not specific to ITP10111213.

A. 8 oz black tea. B. 1 cup canned black beans. C. 8 oz whole milk. D. 15 oz raisins.

Correct Answer is B

Explanation

Choice A rationale
8 oz black tea is not recommended for clients with iron deficiency anemia as it contains tannins, which can inhibit iron absorption.
Choice B rationale
1 cup canned black beans is a good source of non-heme iron, which can help improve iron levels and alleviate fatigue associated with iron deficiency anemia.
Choice C rationale
8 oz whole milk is not a good source of iron and can interfere with the absorption of iron from other foods.
Choice D rationale
15 oz raisins contain some iron but are not as rich in iron as black beans. Additionally, the high sugar content in raisins may not be ideal for all clients.

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A nurse is caring for a client who is 12 hours postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations?

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