A nurse caring for a patient with a water seal type chest drainage that is on low suction assesses that there is constant bubbling in the suction container. The nurse should:

clamp the chest tube and place the patient in high Fowler's position

immediately turn the patient to the side of the insertion site

document findings

check for air leaks in drainage system

Answer and Explanation

The Correct Answer is D

A. Clamp the chest tube and place the patient in high Fowler’s position: Clamping the tube may cause tension pneumothorax and should be done only with a specific prescription.
B. Immediately turn the patient to the side of the insertion site: This action does not address the source of constant bubbling.
C. Document findings: Bubbling in the suction chamber can be normal, but documenting without further assessment may overlook potential system issues.
D. Check for air leaks in the drainage system: Constant bubbling may indicate an air leak, which requires immediate assessment and correction.

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Correct Answer is C

Explanation

A. Examining the character of the sputum: While monitoring secretions is important, it does not necessarily indicate the need for immediate suctioning.
B. Monitoring the rate of respirations: An increased respiratory rate can indicate distress but is not a definitive cue for suctioning.
C. Auscultating the breath sounds: This helps identify the presence of secretions or airway obstruction and is a primary indicator for suctioning.
D. Determining the last time the patient was suctioned: Suctioning should be based on clinical need rather than a routine schedule.

A. Food B. Tongue C. Foreign object D. Medication in pill form

Correct Answer is B

Explanation

A. Food: More common in conscious individuals who are eating.
B. Tongue: The tongue can fall back and block the airway in an unconscious person.
C. Foreign object: Possible but less common than the tongue in unconscious individuals.
D. Medication in pill form: Rare cause of airway obstruction.

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A nurse caring for a patient with a water seal type chest drainage that is on low suction assesses that there is constant bubbling in the suction container. The nurse should:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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