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Respiratory NCLEX Q and A

NCLEX Respiratory Q&A: Chest tube care, expected findings post-thoracotomy, client instructions for removal, and pneumothorax management. Key nursing actions for safe, effective respiratory care.

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NCLEXQA RespiratoryThe nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from therecovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Selectall that apply.1.Excessive bubbling in th e wate r seal chamber2.Vigorous bubbling in the suction control chamber3.Drainage system maintained below the client's chest4.50 mLof drainageinthe drainage collection chamber5.Occlusive dressing in place over the chest tube insertion site6.Fluctuation of water in the tube in the water seal chamber during inhalation andexhalationThe nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the clientto take which action?1.Stay very still.2.Exhale very quickly.3.Inhale and exhale quickly.4.Perform the Valsalva maneuver.The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentlebubblinginthe water seal chamber. What action is mostappropriate?1.Do nothing, because this is an expected finding.2.Check for an air leak, because the bubbling should be intermittent3.Increase the suction pressure so th at the bubbling becom es vigorous.4.Clamp the chest tube and notify the health care provider immediately.The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide bloodreport reveals a level of 1296. Based on this level, the nurse would anticipate noting which sign in the client?1.Coma2.Flushing3.Dizziness4.TachycardiaRationale:Carbon monoxide levels between 11% and 2096 resultinflushing, headache, decreased visual activity, decreasedcerebral functioning, and slight breathlessness: levels of 21% to 40% resultinnausea, vomiting, dizziness, tinnitus,vertigo, confusion, drowsiness, pale to reddish-purple skin, and tachycardia: levels of 4196 to 6096 result in seizureand coma: and levels higher than 6096 result indeath.The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Whichfinding indicates the presence of a pneumothorax in this client?

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National Council Licensure Examination

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