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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. A cough with clear sputum is a common symptom in COPD and does not warrant immediate intervention unless there is a change in the color, consistency, or amount of sputum, which could indicate infection.

B. An oxygen saturation of 95% is within normal limits for most individuals and is often acceptable for clients with COPD, as their target saturation is usually lower (88-92%) to avoid suppressing their hypoxic drive.

C. A respiratory rate of 28 breaths per minute indicates tachypnea, which suggests respiratory distress or worsening of the client’s condition. Immediate assessment and intervention are needed to prevent further deterioration.

D. Mild dyspnea with activity is a common symptom in clients with end-stage COPD and does not require immediate intervention unless it becomes severe or unrelieved with rest.

A. The patient inhales and exhales quickly through pursed lips. B. The patient inhales deeply through the nose and exhales quickly through pursed lips. C. The patient inhales deeply through the nose and exhales slowly through pursed lips. D. The patient inhales deeply through pursed lips and exhales quickly through the nose.

Correct Answer is C

Explanation

A. Inhaling and exhaling quickly through pursed lips does not achieve the intended purpose of pursed-lip breathing. This technique is designed to promote slower, controlled breathing to prevent airway collapse and improve oxygen exchange.

B. Exhaling quickly through pursed lips negates the benefits of pursed-lip breathing. The purpose of this technique is to prolong exhalation, reducing air trapping and improving ventilation.

C. Inhaling deeply through the nose and exhaling slowly through pursed lips is the correct technique for pursed-lip breathing. This method helps maintain open airways, reduces dyspnea, and promotes relaxation.

D. Inhaling deeply through pursed lips and exhaling quickly through the nose is not consistent with proper pursed-lip breathing. The inhalation should be through the nose, and exhalation should be slow and controlled through pursed lips.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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