A nurse is caring for a client who is 24 hours post-thoracotomy with a chest tube connected to a closed drainage system set to -20 cm suction.
The nurse notes the following: Respiratory rate: 22/min, SpO2: 94 The client denies shortness of breath but reports mild incisional pain. Which action should the nurse take?
Clamp the chest tube.
Increase suction pressure to improve lung re-expansion.
Notify the provider of a possible air leak.
Continue to monitor the client's respiratory status.
The Correct Answer is D
This scenario assesses management of post-thoracotomy chest tubes and stable respiratory findings. Knowledge of pleural space physiology, normal post-operative healing, and chest tube safety protocols is required to differentiate between expected recovery milestones and critical complications requiring urgent intervention.
Choice A rationale
Clamping chest tubes is contraindicated unless specifically checking for leaks or changing the drainage system. It risks tension pneumothorax by trapping air or fluid within the pleural space, which can lead to mediastinal shift and cardiovascular collapse.
Choice B rationale
Suction is typically maintained at -20 cm H2O to facilitate lung re-expansion. Increasing suction without a provider order can cause tissue trauma or exacerbate air leaks. The current respiratory rate and oxygen saturation indicate effective drainage and ventilation.
Choice C rationale
Bubbling in the water seal chamber indicates an air leak, but the current clinical data does not suggest one. A respiratory rate of 22 and 94 percent saturation are common 24 hours post-surgery while recovering from anesthesia.
Choice D rationale
Stable vital signs and manageable incisional pain are expected findings. Continuing to monitor ensures the lung remains expanded and the drainage system functions correctly. The SpO2 of 94 percent is acceptable during the early recovery phase after thoracotomy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This scenario requires applying advanced cardiac life support protocols for post-arrest arrhythmias. Knowledge of autonomic nervous system pharmacology is essential to identify the specific medication that increases heart rate by blocking parasympathetic vagal inhibition on the sinoatrial node during symptomatic bradycardia.
Choice A rationale
Magnesium sulfate is primarily utilized to treat torsades de pointes or hypomagnesemia. It acts as a calcium channel blocker in myocardial cells but does not specifically increase heart rate for bradycardia when normal sinus rhythm has already been restored.
Choice B rationale
Sodium bicarbonate is administered to treat specific metabolic acidosis or certain drug toxicities during prolonged arrest. It does not possess chronotropic properties and will not increase the heart rate in a client suffering from a symptomatic slow rhythm.
Choice C rationale
Atropine is an anticholinergic drug that inhibits the vagus nerve, effectively increasing the firing rate of the sinoatrial node. It is the first-line medication for symptomatic bradycardia to improve cardiac output and maintain adequate systemic tissue perfusion.
Choice D rationale
Epinephrine is a potent vasopressor and inotrope used primarily during active pulseless arrest. While it increases heart rate, atropine is specifically indicated first for a restored rhythm that remains slow and symptomatic before progressing to more powerful infusions.
Correct Answer is D
Explanation
Analyzing arterial blood gas results requires understanding the relationship between hydrogen ion concentration, carbon dioxide levels, and bicarbonate. Knowledge of respiratory physiology is essential to determine if the primary imbalance stems from gas exchange failure or metabolic dysfunction in the body.
Choice A rationale
Metabolic acidosis is defined by a low pH and a low bicarbonate level below 22 mEq/L. In this case, the bicarbonate is 26 mEq/L, which is within the normal range of 22 to 28 mEq/L, ruling it out.
Choice B rationale
Respiratory alkalosis occurs when the pH is above 7.45 and the PaCO2 is below 35 mm Hg. This client has a low pH of 7.22 and a high PaCO2 of 68 mm Hg, which indicates an acidotic state.
Choice C rationale
Metabolic alkalosis is characterized by a high pH above 7.45 and an elevated bicarbonate level. This client presents with a low pH and a normal bicarbonate level, which does not fit the criteria for a metabolic alkalotic imbalance.
Choice D rationale
The pH of 7.22 is below 7.35, indicating acidosis. The PaCO2 of 68 mm Hg is above the normal 35 to 45 mm Hg range, confirming a respiratory cause. A respiratory rate of 7/min causes CO2 retention.
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