Question

A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has expanded?

Answer 1

Correct Answers:

No fluctuations in the water seal chamber

Rationale :

💠Absence of fluctuation (tidaling) in the water seal chamber can indicate lung re-expansion or a blockage. ♦️It’s expected when the lung is fully inflated.

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Answer 2

Correct Answers:

"l will wear synthetic clothing and woolen socks when using my oxygen."

Rationale :

♦️Synthetic and wool fabrics can cause static electricity, increasing the risk of fire around oxygen. ♦️ The client needs further teaching.

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Answer 3

Correct Answers:

Autonomy

Rationale :

♦️Honoring the client’s wishes to discontinue ventilator support reflects the ethical principle of autonomy, or the right to make decisions about their care.

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Answer 4

Correct Answers:

The client holds his breath for 10 seconds after inhaling the medication.

Rationale :

♦️After using an albuterol inhaler, the client should hold their breath for ~10 seconds to allow the medication to be absorbed deep in the lungs.

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Answer 5

Correct Answers:

Semi Fowlers

Rationale :

♦️After a pneumonectomy, the client should be positioned in Semi-Fowler’s to promote lung expansion and ease breathing. ♦️Avoid placing them on the operative side.

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Answer 6

Correct Answers:

Place in a prone position.

Rationale :

♦️In ARDS, prone positioning improves oxygenation by enhancing lung recruitment and ventilation-perfusion matching in dorsal lung regions.

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Answer 7

Correct Answers:

Ask the client to read a Snellen chart.

Rationale :

♦️Cranial nerve II (optic nerve) is responsible for vision. ♦️ Using a Snellen chart tests visual acuity and evaluates optic nerve function.

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Answer 8

Correct Answers:

Remind the client to look for food on the left side of the tray.

Rationale :

♦️Homonymous hemianopia is a condition where the client loses the same half of the visual field in both eyes (commonly on the left side after a right-sided stroke). ♦️The nurse should remind the client to scan and look toward the affected side to ensure adequate intake and safety.

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Answer 9

Correct Answers:

Absence of bowel sounds
Weakened gag reflex
Hypotension

Rationale :

♦️Clients with cervical spinal cord injuries are at risk for neurogenic shock, which causes hypotension, loss of autonomic function, and decreased GI motility (absent bowel sounds). ♦️A weakened gag reflex indicates cranial nerve involvement, increasing aspiration risk. ♦️Hyperthermia and polyuria are not expected in the acute phase.

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Answer 10

Correct Answers:

Continuous bubbling in the water seal chamber
Fluctuations in the fluid level in the water seal chamber

Rationale :

♦️Continuous bubbling in the water seal chamber suggests an air leak, which is a complication. ♦️Occasional bubbling in this chamber is expected only during coughing or exhalation. ♦️Constant bubbling is normal in the suction control chamber.

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QLexNursing

1 : A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has expanded?

2 : A nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

4 : A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching?

5 : A nurse in a critical care unit is caring for a client who is postoperative following a right pneumonectomy. After extubation from the ventilator, in which of the following positions should the client be placed?

6 : A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?

7 : A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve II?

8 : A nurse is caring for a client who had a right sided stroke and is exhibiting homonymous hemianopia when eating. Which of the following actions should the nurse take?

9 : A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)

10 : A nurse is caring for a client who has a disposable three chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication?