Following a motor vehicle accident, a client with chest trauma receives a chest tube to relieve a hemothorax. Two hours following the chest tube insertion, the nurse observes the water level in the water-seal chamber is rising during inspiration and falling during expiration. Which action should the nurse implement?
Lift and clear drainage from the chest tube.
Inspect the tube insertion site for leaking.
Continue to monitor the drainage system.
Auscultate lungs for unequal breath sounds.
The Correct Answer is C
Choice A reason: Lifting and clearing drainage from the chest tube is not necessary, as the water level fluctuations indicate that the chest tube is functioning properly and allowing air and fluid to escape from the pleural space.
Choice B reason: Inspecting the tube insertion site for leaking is not indicated, as there is no evidence of air leak in the water-seal chamber. An air leak would cause continuous or intermittent bubbling in the water-seal chamber.
Choice C reason: Continuing to monitor the drainage system is the best action for the nurse to implement, as the water level fluctuations are normal and expected in a water-seal drainage system. The water level should rise during inspiration and fall during expiration, reflecting the changes in intrathoracic pressure.
Choice D reason: Auscultating lungs for unequal breath sounds is not relevant, as it does not address the question of what to do with the water level fluctuations. Unequal breath sounds may indicate a pneumothorax or atelectasis, which are complications of chest trauma or chest tube insertion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is incorrect because hepatorenal failure is a condition that involves both liver and kidney dysfunction, usually as a complication of cirrhosis or portal hypertension. The symptoms of hepatorenal failure may include jaundice, ascites, edema, oliguria, or encephalopathy. However, these are not consistent with the client's presentation of fever, abdominal pain, vomiting, and elevated amylase and lipase levels.
Choice B reason: This is correct because acute pancreatitis is an inflammation of the pancreas that can be caused by gallstones, alcohol abuse, trauma, infection, or drugs. The symptoms of acute pancreatitis may include fever, upper abdominal pain that radiates to the back, nausea, vomiting, and elevated amylase and lipase levels. These are consistent with the client's presentation and suggest that the cholecystectomy may have triggered an attack of acute pancreatitis.
Choice C reason: This is incorrect because surgical site infection is an infection that occurs at or near the incision site after surgery. The symptoms of surgical site infection may include redness, swelling, warmth, pus drainage, or pain at the wound site. However, these are not consistent with the client's presentation of fever, abdominal pain radiating to the back, vomiting, and elevated amylase and lipase levels.
Choice D reason: This is incorrect because biliary duct obstruction is a blockage of the bile ducts that carry bile from the liver and gallbladder to the intestine. The causes of biliary duct obstruction may include gallstones, tumors, inflammation, or scarring. The symptoms of biliary duct obstruction may include jaundice, dark urine, pale stools, itching, or abdominal pain. However, these are not consistent with the client's presentation of fever, abdominal pain radiating to the back, vomiting, and elevated amylase and lipase levels.
Correct Answer is A
Explanation
Choice A reason: Returning for periodic liver function studies is an important instruction for a client with gouty arthritis who is taking colchicine and indomethacin. These medications can cause liver toxicity, which can manifest as jaundice, abdominal pain, nausea, vomiting, and dark urine. The nurse should advise the client to monitor for these signs and symptoms, and to have regular blood tests to check the liver enzymes and function.
Choice B reason: Massaging joints to relax muscles and decrease pain is not a recommended instruction for a client with gouty arthritis who has acute inflammation of the right ankle and great toe. Massage can increase the blood flow and pressure to the affected joints, which can worsen the pain and swelling. The nurse should advise the client to avoid touching or moving the inflamed joints, and to apply ice packs or cold compresses to reduce the inflammation.
Choice C reason: Limiting use of mobility equipment to avoid muscle atrophy is not a necessary instruction for a client with gouty arthritis who has acute inflammation of the right ankle and great toe. Mobility equipment such as crutches, walkers, or canes can help the client to ambulate safely and comfortably, and to prevent further injury or damage to the affected joints. The nurse should encourage the client to use mobility equipment as needed, and to perform gentle range of motion exercises when the inflammation subsides.
Choice D reason: Substituting natural fruit juices for carbonated drinks is not a helpful instruction for a client with gouty arthritis who is taking colchicine and indomethacin. Fruit juices can contain high amounts of fructose, which can increase the uric acid levels in the blood and trigger gout attacks. Carbonated drinks are not a major risk factor for gout, unless they contain high-fructose corn syrup or alcohol. The nurse should advise the client to drink plenty of water, and to avoid foods and beverages that are high in purines, such as organ meats, seafood, beer, and wine.
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