The nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly?

Choice A Reason: This choice is incorrect because hypomagnesemia is not a common finding in the oliguric phase of acute kidney injury. Hypomagnesemia is a condition in which the serum magnesium level is lower than normal (less than 1.5 mEq/L). It may be caused by various factors such as malnutrition, diarrhea, diuretics, or alcohol abuse. It may cause symptoms such as muscle weakness, tremors, tetany, or cardiac arrhythmias.

Choice B Reason: This choice is correct because hyperkalemia is a common finding in the oliguric phase of acute kidney injury. Hyperkalemia is a condition in which the serum potassium level is higher than normal (more than 5 mEq/L). It may be caused by reduced renal excretion of potassium due to decreased urine output (oliguria). It may cause symptoms such as muscle weakness, paresthesia, bradycardia, or cardiac arrest.

Choice C Reason: This choice is incorrect because decreased creatinine level is not a common finding in the oliguric phase of acute kidney injury. Creatinine is a waste product of muscle metabolism that is filtered by the kidneys and excreted in urine. A normal creatinine level ranges from 0.6 to 1.2 mg/dL for men and 0.5 to 1.1 mg/dL for women. In acute kidney injury, creatinine level usually increases due to reduced renal function and impaired clearance of creatinine.

Choice D Reason: This choice is incorrect because increased glomerular filtration rate (GFR) is not a common finding in the oliguric phase of acute kidney injury. GFR is a measure of how well

the kidneys filter blood and remove waste products.

A normal GFR range is 90,to 120 mL/min/1.73 m2. In acute kidney injury, GFR usually decreases due to reduced blood flow,to,the kidneys or damage to the glomeruli, which are the tiny blood vessels that filter blood in the kidneys.

Choice A Reason: Observing for cerebrospinal fluid (CSF) leaks from the evacuation site is important, but not the first action that the nurse should take. CSF leaks can indicate a breach in the dura mater, which can increase the risk of infection and meningitis. The nurse should inspect the dressing and the nose and ears for any clear or bloody drainage, and report any findings to the provider. However, these measures are secondary to ensuring adequate oxygenation and perfusion.

Choice B Reason: The first action the nurse should take when caring for a client post-evacuation of a subdural hematoma is to check the oximeter to ensure adequate oxygenation. Maintaining proper oxygenation is a priority because hypoxia and hypercapnia can lead to cerebral vasodilation, increasing intracranial pressure (ICP) and worsening neurological outcomes.Key Concept: Always prioritize Airway, Breathing, and Circulation (ABCs) when determining the most immediate nursing intervention.

Choice C Reason: Assessing for an increase in temperature is another important action, but not the first one that the nurse should take. An increase in temperature can indicate an infection, inflammation, or damage to the hypothalamus, which can affect the thermoregulation of the body. The nurse should monitor the temperature and administer antipyretics as prescribed. However, these measures are secondary to ensuring adequate oxygenation and perfusion.

Choice D Reason:This is crucial, but oxygenation status should be checked first since low oxygen levels can worsen ICP.