A client with a chest tube shows excessive continuous bubbling in the water seal chamber. After clamping the tube near the dressing, the bubbling continues. What should the nurse do next?

Reinforce the dressing at the connection between the chest tube and the drainage system tubing.

Strip the tube.

Check for kinks in the tubing.

Disconnect the chest tube from the drainage system.

Answer and Explanation

The Correct Answer is A

A chest tube drainage system is used to remove air, blood, or fluid from the pleural space and restore negative intrathoracic pressure. Continuous bubbling in the water seal chamber indicates an air leak in the system. Identifying and correcting the source of the leak is essential to maintain effective lung re-expansion and prevent complications such as tension pneumothorax. Nursing interventions focus on systematically locating the leak starting from the patient site moving toward the drainage system.

Rationale:
A. Reinforcing the dressing at the connection between the chest tube and drainage system tubing is the priority action because persistent bubbling after clamping near the dressing suggests a leak at or near the insertion site or tubing connection. This area is a common source of air leaks. Securing and reinforcing the connection helps restore system integrity and prevents further air entry into the pleural space.

B. Stripping the tube is not recommended because it can create excessively negative pressure within the pleural space. This may lead to tissue trauma, bleeding, or re-expansion pulmonary edema. Current best practice discourages routine stripping or milking of chest tubes as it can worsen patient outcomes rather than resolve air leaks.

C. Checking for kinks in the tubing is an appropriate general assessment, but it does not address the specific finding of continuous bubbling after clamping near the insertion site. Kinks typically result in impaired drainage or lack of fluctuation rather than persistent air leak. Since bubbling continues, the issue is more likely a loose connection or insertion site leak.

D. Disconnecting the chest tube from the drainage system is unsafe and contraindicated. This action can introduce air directly into the pleural space, worsening the pneumothorax and potentially causing tension pneumothorax. Any suspected disconnection should be corrected using sterile technique rather than separating the system entirely.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Suctioning a tracheostomy tube is performed to maintain airway patency by removing accumulated secretions that can obstruct airflow and impair gas exchange. However, the procedure can temporarily reduce oxygen levels and stimulate vagal responses, leading to hypoxia or bradycardia. Therefore, nursing care prioritizes oxygenation, sterile technique, and careful monitoring before, during, and after suctioning. Proper preparation reduces complications and ensures effective airway clearance.

Rationale:
A. Preoxygenating the client with 100% oxygen before suctioning is the priority intervention because it helps prevent hypoxemia during the procedure. Suctioning temporarily removes oxygen from the airway along with secretions, which can quickly lower oxygen saturation. Preoxygenation increases oxygen reserves, maintaining adequate tissue oxygenation during catheter insertion and suctioning.

B. Suctioning continuously while inserting the catheter is incorrect because suction should only be applied while withdrawing the catheter. Continuous suction during insertion can damage tracheal mucosa, cause hypoxia, and remove excessive oxygen from the airway. Proper technique minimizes trauma and preserves oxygenation.

C. Monitoring vital signs only after suctioning is incomplete and unsafe because changes in oxygenation and heart rate can occur during the procedure. Continuous or frequent monitoring before, during, and after suctioning is necessary to detect early signs of hypoxia or vagal stimulation. Delayed monitoring may result in missed complications.

D. Inserting the suction catheter without sterile gloves is unsafe because it increases the risk of introducing pathogens into the lower respiratory tract. Tracheostomy suctioning requires sterile technique to prevent ventilator-associated or hospital-acquired infections. Maintaining sterility is essential for protecting the airway from contamination and infection.

A. Encourage the client to engage in physical therapy to strengthen leg muscles. B. Instruct the client to perform deep breathing exercises every hour. C. Administer low molecular weight heparin as ordered. D. Prepare the client for surgery to remove the embolus.

Correct Answer is C

Explanation

A pulmonary embolism (PE) occurs when a blood clot, usually from the deep veins of the legs, travels to and obstructs the pulmonary arteries. Management priorities depend on the severity and stability of the client. In a low-risk, hemodynamically stable PE, the main goal is to prevent clot extension and new thrombus formation while allowing the body to gradually break down the existing clot. Anticoagulation therapy is the cornerstone of treatment in these cases.

Rationale:
A. Encouraging physical therapy to strengthen leg muscles is not a priority in the acute management of a pulmonary embolism. While mobility and rehabilitation are important in long-term prevention of venous thromboembolism, they do not address the existing clot or prevent immediate progression. The priority is anticoagulation to stabilize the condition before initiating strengthening or exercise programs.

B. Instructing the client to perform deep breathing exercises every hour may support lung expansion and oxygenation, but it does not treat the underlying clot or prevent further embolization. Respiratory exercises are supportive care and are secondary to pharmacologic management. They are useful for preventing atelectasis but are not the priority intervention in acute PE treatment.

C. Administering low molecular weight heparin as ordered is the priority intervention because it prevents further clot formation and propagation. Low molecular weight heparin works by inhibiting clotting factors in the coagulation cascade, reducing the risk of additional emboli. In a stable PE, anticoagulation is the first-line therapy to allow the body’s fibrinolytic system to gradually dissolve the existing clot.

D. Preparing the client for surgery to remove the embolus is not indicated in a low-risk, stable pulmonary embolism. Surgical or catheter-directed embolectomy is reserved for massive or life-threatening PE with hemodynamic instability. In stable patients, invasive procedures are unnecessary and expose the client to additional risks without clear benefit.

View Question and Answer

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

A client with a chest tube shows excessive continuous bubbling in the water seal chamber. After clamping the tube near the dressing, the bubbling continues. What should the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a tracheostomy tube requires suctioning to clear secretions. Which of the following actions should a nurse prioritize to ensure the client's safety and effective airway clearance during the suctioning process?

Correct Answer is A

Explanation

A client is being treated for a low-risk, stable pulmonary embolism (PE). Which of the following interventions should the nurse prioritize to provide effective management?

Correct Answer is C

Explanation

Based on the change of shift report, which client should the nurse assess first?

Which of the following nursing interventions are essential for a client receiving mechanical ventilation to ensure safety and effectiveness? Select All that Apply.

Which of the following statements regarding the management of acute kidney rejection should the nurse include in client education? Select all that apply.

A client on mechanical ventilation has a high pressure alarm triggered. Which of the following actions should the nurse prioritize to address this alarm?

A client is receiving care following the insertion of a Sengstaken-Blakemore tube for esophageal variceal hemorrhage. Which of the following nursing actions is most critical to monitor for potential complications during this intervention?

A nurse is administering IV mannitol to a client diagnosed with cerebral edema. Which of the following actions should the nurse perform prior to the administration of mannitol?

When preparing to administer a blood transfusion, which of the following actions is essential for the nurse to take to ensure client safety?

A client with flail chest is receiving mechanical ventilation. Which of the following interventions is the priority to ensure adequate ventilation and prevent aspiration?