A client is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?

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Question 1 of 5

A client is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?

Correct Answer: C

Rationale: The correct answer is C: Verify that the suction regulator is on and check the tubing for leaks. Rationale: 1. Lack of bubbling in the suction control chamber indicates suction may not be working. 2. Checking the suction regulator ensures it is on and at the correct level for proper drainage. 3. Checking tubing for leaks ensures the system is intact and functioning properly. 4. This intervention addresses the potential issue of inadequate suction, which can affect the client's postoperative recovery. Summary: - Option A: Continuing to monitor is not appropriate as lack of bubbling suggests an issue with suction. - Option B: Adding more water to the suction control chamber is unnecessary and does not address the root cause. - Option D: Milking the chest tube is not recommended as it can cause trauma and dislodging clots may lead to complications.

Question 2 of 5

A client with emphysema is being cared for by a nurse. Which of the following findings should the nurse not expect to assess in this client?

Correct Answer: B

Rationale: Step 1: Emphysema causes impaired gas exchange, leading to dyspnea (A) due to difficulty breathing. Step 2: Emphysema results in hyperinflation of the lungs, causing a barrel chest (C) due to increased chest diameter. Step 3: Clubbing of the fingers (D) is a sign of chronic hypoxia, commonly seen in emphysema. Step 4: Bradycardia (B) is not typically associated with emphysema; tachycardia is more common due to the body compensating for hypoxia.

Question 3 of 5

A client has returned from the surgical suite following surgery for a fractured mandible with intermaxillary fixation. Which of the following actions is the priority for the nurse to take?

Correct Answer: A

Rationale: The correct answer is A: Prevent aspiration. This is the priority because with intermaxillary fixation, the client is unable to open their mouth, increasing the risk of aspiration. Aspiration can lead to serious complications, such as pneumonia. Ensuring the client's airway is clear and they are able to breathe properly should be the top priority. Summary: - B: Ensuring adequate nutrition can be important, but preventing aspiration takes precedence. - C: Promoting oral hygiene is important but not as urgent as preventing aspiration. - D: Relieving the client's pain is essential, but ensuring their safety from aspiration is the priority.

Question 4 of 5

A client has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?

Correct Answer: B

Rationale: The correct answer is B: Weakness. Myasthenia gravis is characterized by muscle weakness due to an autoimmune attack on neuromuscular junctions. Monitoring for weakness is essential to assess disease progression and response to treatment. Confusion (A) is not a typical manifestation of myasthenia gravis. Increased intracranial pressure (C) is more commonly associated with conditions like head trauma or brain tumors. Increased urinary output (D) is not directly related to myasthenia gravis and is more indicative of conditions affecting the kidneys or fluid balance.

Question 5 of 5

During an assessment, a client with a long history of smoking and suspected laryngeal cancer will most likely report which early manifestation?

Correct Answer: B

Rationale: The correct answer is B: Hoarseness. Hoarseness is a common early manifestation of laryngeal cancer due to vocal cord involvement. Smoking is a major risk factor for laryngeal cancer. Dysphagia (choice A) is more commonly associated with esophageal cancer. Dyspnea (choice C) is usually a late manifestation of laryngeal cancer when it causes airway obstruction. Weight loss (choice D) may occur later in the disease progression but is not typically an early sign. Thus, hoarseness is the most likely early manifestation due to its direct connection to the vocal cords and smoking history.

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