A client had a right-sided chest tube inserted two hours ago for pneumothorax. Which action should the nurse implement if there is no fluctuation in the water seal compartment?
Check the chest tube for kinks or obstructions.
Notify the healthcare provider immediately.
Increase the suction pressure on the chest tube.
Continue to monitor the client and reassess in 1 hour.
The Correct Answer is A
A. If there is no fluctuation in the water seal compartment, the first action should be to check for kinks, obstructions, or other issues in the tubing that might block air or fluid movement. Fluctuation (tidaling) is expected during respiration, and its absence may indicate a problem with the system or that the lung has fully re-expanded.
B. Notifying the healthcare provider immediately is not the first step. The nurse should first assess the chest tube system to determine if there is an issue that can be resolved without medical intervention.
C. Increasing the suction pressure on the chest tube is not appropriate without first identifying the cause of the lack of fluctuation. Adjusting suction may not address the underlying problem.
D. Continuing to monitor and reassess in 1 hour delays addressing the potential issue. Immediate assessment of the chest tube system is necessary to ensure proper functioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Tidal fluctuation in the water seal chamber is an expected finding in a chest tube drainage system. It indicates that the pleural space is still connected to the atmosphere, and the lungs are expanding and contracting normally.
B. Continuous bubbling in the suction control chamber is normal when the chest tube is connected to suction. This shows that the suction system is functioning properly.
C. Chest tube eyelets not being visible is expected when the chest tube is properly positioned inside the pleural space. This finding does not require immediate notification.
D. Development of subcutaneous emphysema (air trapped under the skin) may indicate an air leak or improper chest tube placement. This finding requires immediate notification of the provider to address the underlying cause and prevent complications.
Correct Answer is ["31"]
Explanation
- Convert liters to milliliters: 1 liter = 1000 mL
- Calculate total infusion time in minutes: 8 hours 60 minutes/hour = 480 minutes
- Apply the formula:
- (Total volume in mL Drop factor) / Total infusion time in minutes = Drops/minute
- (1000 mL 15 gtts/mL) / 480 minutes = 31.25 gtts/minute
- Round to the nearest whole number: 31 gtts/minute
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