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 ["0.8"]
Explanation
· Set up a proportion: (Desired dose) / (Available concentration) = (Amount to administer)
· Plug in the values: (3,800 units) / (5,000 units/mL) = X mL
· Solve for X: X = 3,800 / 5,000 X = 0.76 mL
· Round to the nearest tenth: X = 0.8 mL
Correct Answer is D
Explanation
A. This description refers to a comminuted fracture, where the bone is broken into multiple fragments. It is not characteristic of a greenstick fracture.
B. This description refers to a compound or open fracture, where the bone breaks through the skin. A greenstick fracture typically does not involve the bone piercing the skin.
C. This description refers to a compression or impacted fracture, where the bone ends are driven into each other. This is not the nature of a greenstick fracture.
D. A greenstick fracture occurs when the bone breaks on one side but bends on the other, similar to how a green twig might break. This is common in children due to the flexibility of their bones.
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