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. An oblique fracture occurs at an angle across the bone and is not characterized by the bone being splintered into several pieces.
B. An impacted fracture occurs when one bone fragment is driven into another, which is not the case here, as the bone is splintered into several pieces.
C. A transverse fracture occurs when the bone breaks in a straight line across the shaft. This does not match the description of the bone being splintered into multiple pieces.
D. A comminuted fracture is when the bone is broken into multiple fragments, which aligns with the description of the client’s fracture. This type of fracture is often caused by high-impact trauma and requires careful management to ensure proper healing.
Correct Answer is D
Explanation
A. Oral hydration is important for overall health and to thin secretions, but it is not the immediate intervention to address dyspnea and wheezing in COPD.
B. Pursed-lip breathing is a helpful technique for managing chronic symptoms of COPD and improving airflow, but it is not the first step in managing acute symptoms like dyspnea and wheezing.
C. Corticosteroid therapy may be part of the treatment for COPD exacerbations, but it is not the initial intervention for acute symptoms. It is typically used after bronchodilators like SABA have been administered.
D. A short-acting beta-agonist (SABA), such as albuterol, is the first-line treatment for acute dyspnea and wheezing in COPD. It works by relaxing the bronchial muscles, opening the airways, and improving airflow.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.