The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube.
Which finding requires immediate reporting?
Intermittent bubbling in the water seal chamber.
Mild crepitus at the insertion site.
Drainage of 75 mL serosanguineous fluid in 1 hour.
Tracheal deviation away from the affected side.
The Correct Answer is D
Chest tube management requires distinguishing between expected findings and signs of tension pneumothorax. Knowledge of thoracic pressure dynamics and complications is essential. Immediate action is required when anatomical shifts indicate a significant increase in pleural pressure and compromised cardiac output.
Choice A rationale
Intermittent bubbling in the water seal chamber is a normal finding in a client with a pneumothorax. It indicates that air is being evacuated from the pleural space during expiration or coughing and does not require immediate reporting.
Choice B rationale
Mild crepitus, or subcutaneous emphysema, is common near the insertion site as small amounts of air leak into the tissues. While it should be monitored for progression, it is not as urgent as signs of mediastinal shift.
Choice C rationale
Drainage of 75 mL per hour of serosanguineous fluid is generally considered within the acceptable range post thoracotomy. Reporting is typically required if drainage exceeds 100 mL per hour or if the color changes to bright red.
Choice D rationale
This is a classic sign of a tension pneumothorax, a medical emergency. Rapid air accumulation increases intrapleural pressure, pushing the mediastinum and trachea toward the unaffected side, which can lead to rapid obstructive shock and death.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E","F"]
Explanation
Diagnosing acute pancreatitis involves analyzing inflammatory markers, pancreatic enzymes, and metabolic changes. Knowledge of systemic inflammatory response syndrome and the endocrine/exocrine functions of the pancreas is necessary to identify labs indicating tissue necrosis, inflammation, and secondary metabolic disturbances.
Choice A rationale
Pancreatitis triggers a systemic inflammatory response, leading to leukocytosis. An elevated white blood cell count (normal range 5,000 to 10,000 cells/mm) is a common finding indicating active inflammation or secondary infection within the pancreatic tissue.
Choice B rationale
In acute pancreatitis, hematocrit often increases rather than decreases due to hemoconcentration. Fluid shifts from the intravascular space into the peritoneal cavity (third spacing) cause a relative rise in hematocrit, indicating significant volume depletion.
Choice C rationale
Serum amylase (normal range 30 to 110 U/L) typically increases rapidly within hours of symptom onset in pancreatitis. A decreased level is not supportive of this diagnosis; levels usually rise three times the upper limit.
Choice D rationale
Serum lipase (normal range 0 to 160 U/L) is a highly specific marker for pancreatic damage. In acute pancreatitis, lipase levels rise significantly and remain elevated longer than amylase, making it a primary diagnostic indicator.
Choice E rationale
Hypertriglyceridemia is both a cause and a result of acute pancreatitis. Serum triglycerides exceeding 1,000 mg/dL can precipitate an attack. Elevated levels support the diagnosis and help identify the potential underlying metabolic etiology.
Choice F rationale
The pancreas produces insulin via islets of Langerhans. Inflammation impairs endocrine function, leading to hyperglycemia (normal fasting glucose 70 to 99 mg/dL). Elevated glucose is a common secondary finding in acute pancreatic injury.
Correct Answer is A
Explanation
Managing esophagogastric balloon tamponade requires knowledge of airway protection and mucosal integrity. Applying nursing interventions for a client with a Sengstaken-Blakemore tube involves preventing complications like aspiration and tissue necrosis while maintaining the mechanical pressure needed for hemostasis.
Choice A rationale
Frequent oral and nares care is essential because the tube causes irritation and prevents the client from swallowing saliva. Secretions accumulate in the upper airway, increasing infection risk and skin breakdown at the insertion site.
Choice B rationale
Clients with a Sengstaken-Blakemore tube must remain strictly NPO to prevent aspiration and avoid disturbing the tube. The balloon occupies the esophagus and stomach to stop variceal bleeding, making oral intake impossible and extremely dangerous.
Choice C rationale
Ambulation is contraindicated for a client with an active balloon tamponade due to the risk of tube displacement. Displacement can lead to airway obstruction if the gastric balloon migrates upward into the oropharynx or trachea.
Choice D rationale
A supine position increases the risk of aspiration and respiratory distress. The nurse should maintain the head of the bed at 30 to 45 degrees to facilitate breathing and minimize the risk of pulmonary complications.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.