Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a client who is 1 day postoperative following a lobectomy and has a chest tube drainage system in place. Which of the following findings by the nurse indicates a need for intervention?
A. Development of subcutaneous emphysema
Choice A: Development of subcutaneous emphysema Reason: Subcutaneous emphysema occurs when air gets trapped under the skin, often due to a leak from the lung or chest tube. This can indicate a serious complication such as a pneumothorax or a malfunctioning chest tube, requiring immediate medical intervention. The presence of subcutaneous emphysema can lead to discomfort, respiratory distress, and further complications if not addressed promptly.
B. Chest tube eyelets not visible
Choice B: Chest tube eyelets not visible Reason: The eyelets of a chest tube are small holes at the end of the tube that allow air and fluid to drain from the pleural space. These eyelets are typically covered by a dressing and may not be visible. This is not necessarily a cause for concern unless there are other signs of malfunction or complications.
C. Continuous bubbling in the suction control chamber
Choice C: Continuous bubbling in the suction control chamber Reason: Continuous bubbling in the suction control chamber is expected and indicates that the suction is functioning properly. It does not indicate a problem unless the bubbling is in the water seal chamber, which would suggest an air leak.
D. Presence of tidal fluctuation in the water seal chamber
Choice D: Presence of tidal fluctuation in the water seal chamber Reason: Tidal fluctuation, or tidaling, in the water seal chamber is a normal finding. It indicates that the chest tube is patent and functioning correctly, as the water level rises with inhalation and falls with exhalation. The absence of tidaling could indicate a blockage or that the lung has fully re-expanded.
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Full Explanation
The correct answer is: a. Development of subcutaneous emphysema
Choice A: Development of subcutaneous emphysema
Reason: Subcutaneous emphysema occurs when air gets trapped under the skin, often due to a leak from the lung or chest tube. This can indicate a serious complication such as a pneumothorax or a malfunctioning chest tube, requiring immediate medical intervention. The presence of subcutaneous emphysema can lead to discomfort, respiratory distress, and further complications if not addressed promptly.
Choice B: Chest tube eyelets not visible
Reason: The eyelets of a chest tube are small holes at the end of the tube that allow air and fluid to drain from the pleural space. These eyelets are typically covered by a dressing and may not be visible. This is not necessarily a cause for concern unless there are other signs of malfunction or complications.
Choice C: Continuous bubbling in the suction control chamber
Reason: Continuous bubbling in the suction control chamber is expected and indicates that the suction is functioning properly. It does not indicate a problem unless the bubbling is in the water seal chamber, which would suggest an air leak.
Choice D: Presence of tidal fluctuation in the water seal chamber
Reason: Tidal fluctuation, or tidaling, in the water seal chamber is a normal finding. It indicates that the chest tube is patent and functioning correctly, as the water level rises with inhalation and falls with exhalation. The absence of tidaling could indicate a blockage or that the lung has fully re-expanded.
Similar Questions
A nurse is caring for a child who is experiencing status asthmaticus. Which of the following interventions is the priority for the nurse to take?
A. Administer inhaled glucocorticoid.
Administering an inhaled glucocorticoid is not the priority intervention for a child with status asthmaticus. Inhaled glucocorticoids are anti-inflammatory drugs that reduce airway inflammation and prevent asthma attacks, but they do not provide immediate relief of bronchoconstriction.
B. Administer a short acting beta agonist (SABA).
Administering a short acting beta agonist (SABA) is the priority intervention for a child with status asthmaticus. SABAs are bronchodilators that relax the smooth muscles of the airways and improve airflow within minutes. They are the first line treatment for acute asthma symptoms and exacerbations.
C. Determine the cause of the acute exacerbation.
Determining the cause of the acute exacerbation is not the priority intervention for a child with status asthmaticus. While it is important to identify and avoid potential triggers of asthma, such as allergens, infections, or stress, this is not an urgent action during a severe asthma attack.
D. Obtain a peak flow reading
Obtaining a peak flow reading is not the priority intervention for a child with status asthmaticus. Peak flow is a measure of how quickly the child can blow air out of the lungs, and it can indicate the degree of airway obstruction. However, peak flow measurement is not reliable or feasible during a severe asthma attack, and it should not delay the administration of bronchodilators.
Full Explanation
Choice A reason: Administering an inhaled glucocorticoid is not the priority intervention for a child with status asthmaticus. Inhaled glucocorticoids are anti-inflammatory drugs that reduce airway inflammation and prevent asthma attacks, but they do not provide immediate relief of bronchoconstriction.
Choice B reason: Administering a short acting beta agonist (SABA) is the priority intervention for a child with status asthmaticus. SABAs are bronchodilators that relax the smooth muscles of the airways and improve airflow within minutes. They are the first line treatment for acute asthma symptoms and exacerbations.
Choice C reason: Determining the cause of the acute exacerbation is not the priority intervention for a child with status asthmaticus. While it is important to identify and avoid potential triggers of asthma, such as allergens, infections, or stress, this is not an urgent action during a severe asthma attack.
Choice D reason: Obtaining a peak flow reading is not the priority intervention for a child with status asthmaticus. Peak flow is a measure of how quickly the child can blow air out of the lungs, and it can indicate the degree of airway obstruction. However, peak flow measurement is not reliable or feasible during a severe asthma attack, and it should not delay the administration of bronchodilators.
A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration?
A. Reposition the client toward the left side.
Repositioning the client toward the left side is not necessary or helpful for a client who has a three-chamber closed chest tube system. The chest tube drainage system must always be placed below the drainage site and secured in an upright position to prevent it from being knocked over.
B. Continue to monitor the client.
Continuing to monitor the client is the appropriate action for the nurse to take after noticing a rise in the water seal chamber with client inspiration. The water in the water seal chamber should rise with inhalation and fall with exhalation (this is called tidaling), which demonstrates that the chest tube is patent. This is a normal finding and does not indicate a problem with the chest tube system or the client's condition.
C. Clamp the chest tube near the water seal.
Clamping the chest tube near the water seal is not recommended for a client who has a three-chamber closed chest tube system. Clamping the chest tube can cause a buildup of air or fluid in the pleural space and increase the risk of complications such as tension pneumothorax or infection. Clamping the chest tube should only be done in certain situations, such as changing the drainage system, checking for an air leak, or removing the chest tube.
D. Immediately notify the provider.
Immediately notifying the provider is not necessary for a client who has a three-chamber closed chest tube system and shows a rise in the water seal chamber with client inspiration. As mentioned above, this is a normal finding and does not indicate a problem with the chest tube system or the client's condition. The nurse should only notify the provider if there are signs of complications, such as continuous bubbling in the water seal chamber, excessive drainage, chest pain, dyspnea, or subcutaneous emphysema.
Full Explanation
Choice A reason: Repositioning the client toward the left side is not necessary or helpful for a client who has a three-chamber closed chest tube system. The chest tube drainage system must always be placed below the drainage site and secured in an upright position to prevent it from being knocked over.
Choice B reason: Continuing to monitor the client is the appropriate action for the nurse to take after noticing a rise in the water seal chamber with client inspiration. The water in the water seal chamber should rise with inhalation and fall with exhalation (this is called tidaling), which demonstrates that the chest tube is patent. This is a normal finding and does not indicate a problem with the chest tube system or the client's condition.
Choice C reason: Clamping the chest tube near the water seal is not recommended for a client who has a three-chamber closed chest tube system. Clamping the chest tube can cause a buildup of air or fluid in the pleural space and increase the risk of complications such as tension pneumothorax or infection. Clamping the chest tube should only be done in certain situations, such as changing the drainage system, checking for an air leak, or removing the chest tube.
Choice D reason: Immediately notifying the provider is not necessary for a client who has a three-chamber closed chest tube system and shows a rise in the water seal chamber with client inspiration. As mentioned above, this is a normal finding and does not indicate a problem with the chest tube system or the client's condition. The nurse should only notify the provider if there are signs of complications, such as continuous bubbling in the water seal chamber, excessive drainage, chest pain, dyspnea, or subcutaneous emphysema.
A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed head injury. Which of the following actions should the nurse take?
A. Use log rolling to reposition the client.
Using log rolling to reposition the client is not advisable for a client who has increased ICP. Log rolling is a technique that involves moving the client as a unit, without flexing the spine, to prevent spinal cord injury. However, log rolling can also increase ICP by reducing venous drainage from the head and increasing cerebral blood volume. Therefore, the nurse should avoid log rolling the client unless there is a suspected spinal injury.
B. Instruct the client to cough and deep breathe.
Instructing the client to cough and breathe deep is not appropriate for a client who has increased ICP. Coughing and deep breathing can increase intrathoracic pressure, which can reduce venous return to the heart and increase ICP. Additionally, coughing and deep breathing can cause hyperventilation, which can lower the partial pressure of carbon dioxide in the blood and cause cerebral vasoconstriction. This can reduce cerebral perfusion and oxygen delivery to the brain.
C. Place a warming blanket on the client.
Placing a warming blanket on the client is not recommended for a client who has increased ICP. A warming blanket can increase the body temperature, which can increase the metabolic rate and oxygen demand of the brain. This can worsen cerebral ischemia and edema. Moreover, a warming blanket can cause vasodilation, which can increase cerebral blood volume and ICP. Therefore, the nurse should maintain a normal body temperature for the client and avoid hyperthermia.
D. Place the client in a supine position.
Placing the client in a supine position is the best action for the nurse to take for a client who has increased ICP. The supine position is a way of lying on a table with the back, face, and abdomen facing upwards. It is used for various surgeries and examinations, such as cranial, cardiac, abdominal, and thoracic surgery. It can also prevent respiratory, skin, and circulatory problems. The supine position can help lower ICP by facilitating venous drainage from the head and reducing cerebral blood volume [^10^]. However, the nurse should also elevate the head of the bed to 30 degrees to optimize cerebral perfusion pressure and avoid neck flexion or rotation, which can impair venous drainage.
Full Explanation
Choice A reason: Using log rolling to reposition the client is not advisable for a client who has increased ICP. Log rolling is a technique that involves moving the client as a unit, without flexing the spine, to prevent spinal cord injury. However, log rolling can also increase ICP by reducing venous drainage from the head and increasing cerebral blood volume. Therefore, the nurse should avoid log rolling the client unless there is a suspected spinal injury.
Choice B reason: Instructing the client to cough and breathe deep is not appropriate for a client who has increased ICP. Coughing and deep breathing can increase intrathoracic pressure, which can reduce venous return to the heart and increase ICP. Additionally, coughing and deep breathing can cause hyperventilation, which can lower the partial pressure of carbon dioxide in the blood and cause cerebral vasoconstriction. This can reduce cerebral perfusion and oxygen delivery to the brain.
Choice C reason: Placing a warming blanket on the client is not recommended for a client who has increased ICP. A warming blanket can increase the body temperature, which can increase the metabolic rate and oxygen demand of the brain. This can worsen cerebral ischemia and edema. Moreover, a warming blanket can cause vasodilation, which can increase cerebral blood volume and ICP. Therefore, the nurse should maintain a normal body temperature for the client and avoid hyperthermia.
Choice D reason: Placing the client in a supine position is the best action for the nurse to take for a client who has increased ICP. The supine position is a way of lying on a table with the back, face, and abdomen facing upwards. It is used for various surgeries and examinations, such as cranial, cardiac, abdominal, and thoracic surgery. It can also prevent respiratory, skin, and circulatory problems. The supine position can help lower ICP by facilitating venous drainage from the head and reducing cerebral blood volume [^10^]. However, the nurse should also elevate the head of the bed to 30 degrees to optimize cerebral perfusion pressure and avoid neck flexion or rotation, which can impair venous drainage.