Which of the following assessment findings indicates an emergency and the need for immediate action on the part of the nurse?

Clubbing of the fingernails

Tracheal deviation

Contraction of the diaphragm

Auscultation of rhonchi throughout the lungs

Answer and Explanation

The Correct Answer is B

A. Clubbing of the fingernails is typically a sign of chronic hypoxia and is seen in conditions like cystic fibrosis, COPD, and other respiratory or cardiovascular diseases. It is a long-term issue and does not indicate an immediate emergency.
B. Tracheal deviation is a medical emergency and typically indicates tension pneumothorax, where air accumulates in the pleural space, shifting the trachea away from the affected side. This can compress the heart and lungs, leading to respiratory and circulatory collapse, requiring immediate action.
C. Contraction of the diaphragm may refer to normal breathing mechanics and does not indicate an immediate emergency unless it is associated with respiratory distress or failure.
D. Rhonchi are abnormal lung sounds often associated with mucus in the airways and can be heard in conditions like bronchitis or COPD. Although they may require attention, they do not represent an immediate emergency compared to tracheal deviation.

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Correct Answer is B

Explanation

A. Maintaining an IV of 0.45% sodium chloride would not be appropriate for SIADH because it is a hypotonic solution, and it could exacerbate the already low sodium levels in the patient, potentially worsening hyponatremia.
B. Fluid restriction is the primary treatment for SIADH as it helps reduce water retention, which is causing the dilution of sodium in the blood. Restricting fluid intake to 1,000 mL per day helps manage hyponatremia in these patients.
C. A diet containing 2 g of sodium per day is not typically indicated in SIADH. Restricting fluid is the main focus, and increasing sodium intake can often be counterproductive in SIADH, as the sodium imbalance is primarily due to excessive water retention.
D. Desmopressin acetate is typically used in diabetes insipidus, not SIADH. Desmopressin acts as an antidiuretic hormone (ADH) agonist, which would worsen the water retention in SIADH, not improve it.

A. Constant bubbling in the suction-control chamber B. Continuous bubbling in the water-seal chamber C. Fluid-level fluctuations in the water-seal chamber D. Bloody drainage in the collection chamber

Correct Answer is B

Explanation

A. Constant bubbling in the suction-control chamber is normal as it indicates that the suction is active and functioning as intended. The chamber should have steady bubbling when suction is applied.
B. Continuous bubbling in the water-seal chamber is abnormal and indicates a potential air leak. The water-seal chamber should only bubble intermittently with respiratory effort or changes in pressure; constant bubbling suggests that air is being introduced into the system, which could indicate a malfunction or an air leak at the insertion site or along the tubing.
C. Fluid-level fluctuations in the water-seal chamber are normal and should be observed, especially with breathing. The fluid levels will rise with inspiration and fall with expiration, reflecting the changes in pressure within the pleural space.
D. Bloody drainage in the collection chamber is expected immediately after surgery, particularly in the early postoperative period. It may be a sign of surgical site drainage, but if it becomes excessive or persists, further assessment is required. However, a small amount of blood in the collection chamber initially is not abnormal.

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Which of the following assessment findings indicates an emergency and the need for immediate action on the part of the nurse?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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