A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?

Continue to monitor the client's respiratory status.

Check the suction control outlet on the wall.

Clamp the chest tube.

Check the tubing connections for leaks.

Answer and Explanation

The Correct Answer is A

Choice A Reason: This choice is correct because slow, steady bubbling in the suction control chamber indicates that the suction is working properly and maintaining a negative pressure in the pleural space. The nurse should continue to monitor the client's respiratory status, such as breath sounds, oxygen saturation, and respiratory rate, to assess the eﬀectiveness of the chest drainage system.

Choice B Reason: This choice is incorrect because checking the suction control outlet on the wall is not necessary unless there is no bubbling in the suction control chamber, which would indicate a problem with the suction source or setting. The nurse should ensure that the suction control outlet is set at the prescribed level, usually between 10 and 20 cm H2O.

Choice C Reason: This choice is incorrect because clamping the chest tube is not indicated unless there is a leak in the system or the chest drainage unit needs to be changed. Clamping the chest tube may cause a buildup of air or ﬂuid in the pleural space, which can lead to tension pneumothorax or pleural eﬀusion.

Choice D Reason: This choice is incorrect because checking the tubing connections for leaks is not necessary unless there is continuous bubbling in the water seal chamber, which would indicate an air leak in the system. The nurse should ensure that all tubing connections are tight and secure, and tape any loose connections.

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Correct Answer is D

Explanation

Choice A Reason: This is incorrect because crepitus in the area above and surrounding the insertion site is not a serious finding that requires notification of the provider. Crepitus is a crackling sensation that occurs when air leaks into the subcutaneous tissue. It is usually harmless and resolves on its own.

Choice B reason: This is incorrect because bubbling of the water in the water seal chamber with exhalation is a normal finding that indicates that air is being removed from the pleural space. Bubbling should stop when the pneumothorax is resolved.

Choice C Reason: This is incorrect because eyelets are not visible is not a serious finding that requires notification of the provider. Eyelets are small holes at the end of the chest tube that allow air and ﬂuid to drain from the pleural space. They are usually covered by a dressing and may not be visible.

Choice D Reason: This is correct because movement of the trachea toward the unaﬀected side is a serious finding that indicates a tension pneumothorax, which is a life-threatening condition that occurs when air accumulates in the pleural space and causes pressure on the mediastinum. The nurse should notify the provider immediately and prepare for needle decompression or chest tube insertion.

A. 54 percent B. 36 percent C. 18 percent D. 9 percent

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.

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A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

Correct Answer is D

Explanation

A nurse in an emergency department is caring for an adult client who has burns on the front and back of both his legs and arms. Using the rule of nines, the nurse should document burns to which percentage of the client's total body surface area (TBSA)?

Correct Answer is A

Explanation

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