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.

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

This scenario requires applying knowledge of burn pathophysiology, fluid resuscitation, and emergency prioritization. Assessing deep tissue damage involves monitoring for systemic complications such as hypovolemia or airway compromise. Critical thinking is needed to distinguish between expected post-burn symptoms and life-threatening physiological shifts.

Choice A rationale

A saturation of 95 percent is within the acceptable normal range of 95 to 100 percent. While chest burns can impact ventilation, this specific value indicates adequate oxygenation and is not currently a priority over circulatory concerns.

Choice B rationale

Normal urinary output is ≥ 0.5 mL/kg/hr or roughly 30 mL/hr. An output of 25 mL/hr indicates poor renal perfusion or hypovolemia. This suggests inadequate fluid resuscitation, which is a life-threatening complication in major burn injuries.

Choice C rationale

Pain is expected with partial-thickness burns due to exposed nerve endings. While severe pain requires intervention, it is considered a psychosocial or non-life-threatening priority compared to hemodynamic instability or organ failure signaled by low urine output.

Choice D rationale

Localized edema is a standard inflammatory response in burn victims caused by increased capillary permeability. It is an expected finding within the first 24 to 48 hours and does not indicate an immediate systemic crisis.

A. A client 1 day post-op with a temperature of 38.2°C (100.9°F). B. A client with pancreatitis reporting abdominal pain 8/10 and nausea. C. A client with cirrhosis who is increasingly confused and has asterixis. D. A client with a potassium level of 6.8 mEq/L who has peaked T waves on ECG.

Correct Answer is D

Explanation

Nursing prioritization relies on the ABC framework and identifying the most immediate threat to life. Knowledge of electrolyte imbalances and cardiac conduction must be applied here to recognize that severe hyperkalemia poses an imminent risk of lethal cardiac arrhythmias.

Choice A rationale

A low grade fever of 38.2 C on the first postoperative day is common due to the inflammatory response or atelectasis. While it requires monitoring and lung expansion exercises, it is not an immediate life threat.

Choice B rationale

Severe abdominal pain and nausea are classic symptoms of acute pancreatitis. While the patient is in significant distress and needs analgesia, this presentation is expected for the diagnosis and is second to cardiovascular instability.

Choice C rationale

Confusion and asterixis in cirrhosis indicate hepatic encephalopathy due to elevated ammonia. Normal ammonia is 15 to 45 mcg/dL. This requires treatment with lactulose but is less immediately fatal than a cardiac arrest.

Choice D rationale

A potassium level of 6.8 mEq/L is critically high, as the normal range is 3.5 to 5.0 mEq/L. Peaked T waves indicate myocardial irritability, which can progress rapidly to ventricular fibrillation or asystole, requiring emergent intervention..

View Question and Answer

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

The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. Which finding requires immediate reporting?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area. The client has T 100.4 F, P 100, R 24, and BP 102/60. The client is complaining of severe pain. Which assessment data is most concerning to the nurse?

Correct Answer is B

Explanation

The nurse received the morning shift report on four clients. Which client should the nurse assess first?

Correct Answer is D

Explanation

An adult weighing 88 kg is brought to the emergency department after sustaining a thermal injury. Burns are partial and full thickness over 38 According to the Parkland formula, what would this client's fluid requirements be for the first 24 hours after injury?

The nurse provides discharge teaching to a client who had a myocardial infarction. Which statements by the client indicate an understanding? Select all that apply.

A nurse is teaching a client who has a prescription of a nasogastric tube (NG) to treat a pyloric obstruction. Which of the following rationales for the use of the nasogastric tube should the nurse include in the teaching?

A client with a full-thickness burn to the lower extremity is stable and receiving ongoing care. Which task is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?

A client presents to the emergency department with a sudden onset of left-sided weakness, difficulty speaking, and a facial droop on the left side. Which action should the nurse prioritize?

The nurse is delegating care for a client with a stroke who has dysphagia. Which task is appropriate to assign to the unlicensed assistive personnel (UAP)?

An intubated client with increased intracranial pressure has pooled secretions in the airway. Which action should the nurse take first?

The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube.
Which finding requires immediate reporting?