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 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.

A. Let the client rest alone in a quiet, calm environment. B. Reassure the client that the doctor will arrive soon. C. Place the client on a cardiac monitor and observe from the nurse's station. D. Stay with the client and encourage pursed-lip breathing.

Correct Answer is D

Explanation

A. Letting the client rest alone is not an appropriate intervention for an asthma attack. The client needs reassurance and support during an asthma exacerbation, and isolation can increase anxiety and worsen symptoms.

B. Reassuring the client that the doctor will arrive soon may provide some comfort, but it does not directly address the acute symptoms of dyspnea and anxiety. Immediate interventions to manage the asthma attack should be prioritized.

C. Placing the client on a cardiac monitor and observing from the nurse's station may be appropriate for monitoring heart rate and rhythm, but it does not address the primary concern of managing the asthma attack or anxiety. The nurse should be present to provide direct support and interventions.

D. Staying with the client and encouraging pursed-lip breathing is an effective intervention for managing anxiety and dyspnea during an asthma attack. Pursed-lip breathing helps the client slow their breathing, improve ventilation, and reduce anxiety, which can alleviate dyspnea.

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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

A nurse is caring for a client who has a fractured tibia as a result of a fall. The client’s x-ray shows that the bone is splintered into several pieces around the shaft. The nurse should identify that the client has which of the following types of fractures?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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