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 C
Explanation
A. Assessing the patient’s vital signs is important but is not the first priority during an acute asthma attack. The primary concern is airway patency and breathing effectiveness.
B. Checking the patient’s blood pressure is part of a comprehensive assessment but is not the immediate priority in this scenario. It does not directly address the respiratory distress associated with an asthma attack.
C. Assessing the patient’s lung sounds is the first priority as it provides critical information about the severity of the airway obstruction and the effectiveness of the patient’s breathing. Identifying wheezing, diminished breath sounds, or silent chest (absence of airflow) is essential for immediate intervention.
D. Obtaining a complete medical history is important for long-term management but is not the priority during an acute asthma attack. Immediate assessment and stabilization take precedence.
Correct Answer is ["A","C","D"]
Explanation
A. Decreased PaO2 <60mmHg: A hallmark of fat embolism syndrome (FES) is hypoxemia, which results in a PaO2 less than 60 mmHg. This is a key indicator of the severity of respiratory compromise in FES and ARDS.
B. PaO2 greater than 80mmHg: This would not be consistent with FES. Fat embolism often causes significant hypoxemia, and PaO2 greater than 80 mmHg would indicate adequate oxygenation.
C. Decreased platelet count and hematocrit levels: In fat embolism syndrome, there is often a decrease in platelet count and hematocrit due to disseminated intravascular coagulation (DIC), which can occur as a complication of fat embolism.
D. Changes in ST segment and T-wave: Electrocardiographic changes, including changes in ST segment and T-wave, are commonly seen in fat embolism syndrome due to myocardial injury, hypoxemia, or shock.
E. PaCO2 40mmHg: A PaCO2 of 40 mmHg is within normal limits and does not indicate any significant respiratory distress or abnormality that would be expected in fat embolism syndrome.
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