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Adult Health - Respiratory – Silvestri Exam Solution Latest Update
The nurse is assessing the functioning of a chest tube drainage system in a client who
has just returned from the recovery room following a thoracotomy with wedge resection.
Which are the expected assessment findings? Select all that apply. - ANS-Drainage
system maintained below the client's chest
4.
50 mL of drainage in the drainage collection chamber
5.
Occlusive dressing in place over the chest tube insertion site
6.
Fluctuation of water in the tube in the water seal chamber during inhalation and
exhalation
The nurse is assisting a health care provider with the removal of a chest tube. The
nurse should instruct the client to take which action? - ANS-Perform the Valsalva
maneuver.
The nurse caring for a client with a pneumothorax and who has had a chest tube
inserted notes continuous gentle bubbling in the water seal chamber. What action is
most appropriate? - ANS-Check for an air leak, because the bubbling should be
intermittent.
The nurse is caring for a client who suffered an inhalation injury from a wood stove. The
carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse
would anticipate noting which sign in the client? - ANS-Flushing
The emergency department nurse is assessing a client who has sustained a blunt injury
to the chest wall. Which finding indicates the presence of a pneumothorax in this client?
- ANS-Diminished breath sounds
The nurse is caring for a client hospitalized with acute exacerbation of chronic
obstructive pulmonary disease. Which findings would the nurse expect to note on
assessment of this client? Select all that apply. - ANS-A hyperinflated chest noted on
the chest x-ray
3.
Decreased oxygen saturation with mild exercise
The nurse instructs a client to use the pursed-lip method of breathing and evaluates the
teaching by asking the client about the purpose of this type of breathing. The nurse
determines that the client understands if the client states that the primary purpose of
pursed-lip breathing is to promote which outcome? - ANS-Promote carbon dioxide
elimination.
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