A nurse is caring for a client who is postoperative and has a chest tube drainage system. For which of the following findings should the nurse notify the provider?
Presence of 50 mL/hr in the drainage chamber
Tidaling occurs when the client is breathing
Continuous bubbling in the water seal chamber
Oxygen saturation of 92% on room air
The Correct Answer is C
A. Presence of 50 mL/hr in the drainage chamber: Some drainage after chest tube placement is expected. A rate of 50 mL/hr is within a typical range for postoperative monitoring, especially in the first 24 hours, and does not usually require immediate provider notification unless it increases significantly or becomes bloody.
B. Tidaling occurs when the client is breathing: Tidaling, or the rise and fall of fluid in the water seal chamber with respiration, indicates that the chest tube system is patent and functioning correctly. This is an expected finding and reflects normal intrathoracic pressure changes during breathing.
C. Continuous bubbling in the water seal chamber: Continuous bubbling in the water seal chamber suggests an air leak in the system. This is abnormal and requires provider notification because persistent air leaks can impair lung re-expansion, compromise respiratory function, and may indicate malfunction of the system or a worsening pneumothorax.
D. Oxygen saturation of 92% on room air: An oxygen saturation of 92% is slightly below normal but may be expected immediately postoperative or in clients with lung compromise. It requires monitoring and supplemental oxygen if needed, but it is not as urgent as a continuous air leak in the chest tube system.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Monitor the dorsalis pedis pulse every 15 min: Frequent assessment of peripheral pulses, such as the dorsalis pedis, is essential after a cardiac catheterization to detect early signs of arterial occlusion, bleeding, or compromised circulation. Monitoring every 15 minutes during the initial post-procedure period allows timely identification of complications.
B. Place the client in Fowler's position: After a femoral cardiac catheterization, the client is typically positioned supine with the affected leg straight to minimize bleeding and hematoma formation. Fowler’s position can increase stress on the groin puncture site and is not recommended immediately post-procedure.
C. Keep the client NPO for 24 hr: NPO status is not routinely required for 24 hours following cardiac catheterization. Clients may resume oral intake as tolerated once hemodynamically stable, unless contraindicated for other medical reasons.
D. Maintain strict bedrest for the first 12 hr: While bedrest is necessary immediately post-procedure, strict immobility is usually required for 2–6 hours, depending on the type of closure device or sheath used. Maintaining 12 hours of strict bedrest is longer than standard protocol and may unnecessarily increase discomfort and risk of complications like urinary retention.
Correct Answer is D
Explanation
A. Outer posterior aspect of upper arm: This site, the deltoid muscle, is appropriate for small-volume IM injections (up to 1 mL). However, it is limited by muscle size and is not preferred for larger volume or more irritating medications.
B. Upper thigh: The vastus lateralis muscle of the anterior thigh is a common IM site, particularly in infants and young children. While suitable, it may be less preferred in adults unless other sites are contraindicated.
C. Abdomen: The abdomen is not used for intramuscular injections; it is a common site for subcutaneous injections, such as insulin or heparin. Administering an IM injection in the abdomen would risk improper absorption and injury.
D. Ventrogluteal: The ventrogluteal site is preferred for intramuscular injections in adults because it is away from major nerves and blood vessels, allows for larger volumes of medication, and has a consistent muscle mass. It minimizes the risk of complications and is considered the safest IM injection site.
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