a patient with a chest tube has continuous bubbling in the water seal chamber what does this indicate

ATI RN

ATI Capstone Medical Surgical Assessment 2 Quizlet

1. What does continuous bubbling in the water seal chamber of a chest tube indicate?

A. An air leak
B. Normal chest tube function
C. A blockage in the chest tube
D. A malfunction in the drainage system

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber of a chest tube indicates an air leak. This bubbling occurs when air leaks from the patient's pleural space into the chest tube system. It is essential to address this issue promptly to prevent complications like a pneumothorax. Choices B, C, and D are incorrect because continuous bubbling in the water seal chamber is not indicative of normal chest tube function, a blockage in the chest tube, or a malfunction in the drainage system.

2. What are the expected findings in a patient with a thrombotic stroke?

A. Gradual loss of function on one side of the body
B. Sudden loss of consciousness
C. Severe headache and vomiting
D. Loss of sensation in the affected limb

Correct answer: A

Rationale: The correct answer is A: Gradual loss of function on one side of the body. In a thrombotic stroke, a blood clot forms in an artery supplying blood to the brain, leading to reduced blood flow to a specific area of the brain. This results in a gradual onset of neurological deficits, such as weakness, numbness, or paralysis on one side of the body. Choices B, C, and D are incorrect because sudden loss of consciousness, severe headache and vomiting, and loss of sensation in the affected limb are more commonly associated with other types of strokes or medical conditions, not specifically thrombotic strokes. Thrombotic strokes typically present with gradual symptoms due to the gradual blockage of blood flow, leading to a progressive neurological deficit.

3. What lab value should be prioritized for a patient with HIV?

A. CD4 T-cell count below 180 cells/mm3
B. Serum albumin levels
C. White blood cell count
D. Hemoglobin levels

Correct answer: A

Rationale: A CD4 T-cell count below 180 cells/mm3 should be prioritized for a patient with HIV. This value is crucial as it indicates severe immunocompromise in HIV-infected individuals. Monitoring CD4 T-cell count helps assess the status of the immune system and guides treatment decisions. Serum albumin levels (choice B) may reflect the patient's nutritional status and overall health but are not as specific to HIV disease progression. White blood cell count (choice C) and hemoglobin levels (choice D) can be affected by various factors and are not as directly linked to HIV management as the CD4 T-cell count in this context.

4. A nurse is admitting a client who has suspected appendicitis. Which of the following findings should the nurse report to the provider immediately?

A. Distended, board-like abdomen
B. WBC count of 15,000/mm3
C. Rebound tenderness over McBurney's point
D. Temperature of 37.3°C (99.1°F)

Correct answer: A

Rationale: A distended, board-like abdomen should be reported to the provider immediately because it indicates peritonitis, a serious complication of appendicitis resulting from a ruptured appendix. Option B, an elevated WBC count, may indicate infection but is not as urgent as a board-like abdomen. Option C, rebound tenderness over McBurney's point, is a classic sign of appendicitis but does not indicate immediate life-threatening complications. Option D, a slightly elevated temperature, is not as concerning as a distended, board-like abdomen.

5. What is the first medication to give to a patient with wheezing due to an allergic reaction?

A. Albuterol via nebulizer
B. Methylprednisolone 100 mg IV
C. Cromolyn 20 mg via nebulizer
D. Aminophylline 500 mg IV

Correct answer: A

Rationale: The correct answer is A, Albuterol via nebulizer. Albuterol is the first-line treatment for wheezing caused by an allergic reaction because it is a fast-acting bronchodilator that helps to quickly open the airways, providing immediate relief of symptoms. Choice B, Methylprednisolone 100 mg IV, is a corticosteroid used for its anti-inflammatory effects but is not the initial medication for acute wheezing in an allergic reaction. Choice C, Cromolyn 20 mg via nebulizer, is a mast cell stabilizer that can be used for prevention but is not the first choice for acute symptom relief. Choice D, Aminophylline 500 mg IV, is a bronchodilator with a narrow therapeutic window and more side effects compared to Albuterol, making it a less preferred option as the initial treatment.