The healthcare provider is caring for a client with a chest tube. Which assessment finding requires immediate intervention?

Correct Answer: C

Rationale: The correct answer is C: Crepitus around the insertion site. Crepitus suggests subcutaneous emphysema, which can indicate a pneumothorax or air leak. Immediate intervention is needed to prevent further complications. A: Intermittent bubbling in the water seal chamber is expected and indicates a functioning chest tube system. B: Drainage of 75 ml in the first hour post-insertion is within the normal range and should be monitored. D: Fluctuation of the water level in the water seal chamber with respiration is a normal finding indicating the chest tube is functioning correctly.

Correct Answer: D

Rationale: The correct answer is D: Potassium level of 6.5 mEq/L. High potassium levels (hyperkalemia) in CKD patients receiving hemodialysis can lead to serious complications like cardiac arrhythmias or even cardiac arrest. Therefore, it is crucial to report this finding immediately to the healthcare provider for prompt intervention. Explanation for other choices: A: Blood pressure of 150/90 mm Hg - While elevated, this blood pressure reading is not an immediate concern unless accompanied by symptoms like chest pain or shortness of breath. B: Weight gain of 2 pounds since the last dialysis session - While weight gain may indicate fluid retention, it is not an urgent issue unless it is rapid and significant. C: Blood glucose level of 120 mg/dl - A blood glucose level of 120 mg/dl is within the normal range and does not require immediate action in this context.

Correct Answer: C

Rationale: The correct answer is C: Monitor your blood glucose levels regularly. This is important because metformin helps lower blood sugar levels, and monitoring glucose levels helps ensure the medication is effective and the client is not experiencing hypoglycemia or hyperglycemia. Option A is incorrect because metformin should be taken with meals to reduce gastrointestinal side effects. Option B is incorrect as metformin does not typically require fluid restriction. Option D is incorrect as metformin does not affect potassium levels. Regularly monitoring blood glucose levels is crucial for managing type 2 diabetes effectively.

Correct Answer: A

Rationale: The correct answer is A: Continuous tube feeding at 65 ml/hr via gastrostomy. Dysphagia, hypoactive bowel sounds, and a distended abdomen indicate a potential risk for aspiration or impaired gastrointestinal motility. Continuous tube feeding may worsen these conditions. The nurse should question this prescription to prevent further complications. Choices B, C, and D are not immediate concerns for dysphagia and bowel issues. Total parenteral nutrition, nasogastric tube connected to suction, and metoclopramide can be appropriate interventions for nutritional support and bowel motility in this scenario.

Correct Answer: C

Rationale: Rationale: Option C, on-call sedation administered, is the correct answer because sedation is essential for bronchoscopy to ensure the client is comfortable and cooperative during the procedure. Sedation helps reduce anxiety and discomfort, making the procedure more tolerable. Options A, B, and D are incorrect as they do not directly indicate readiness for the procedure. Denying allergies to contrast media (A) is important but not specific to bronchoscopy readiness. Skin prep completion (B) is part of the pre-procedure preparation but does not confirm readiness. Oxygen administration (D) is a routine care measure and does not indicate readiness for bronchoscopy.