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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
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.
Correct Answer is ["A","B","D"]
Explanation
A. Aspirated vomit: Can obstruct the airway or cause aspiration pneumonia, reducing oxygenation.
B. Pulmonary fibrosis: Scarring of lung tissue impairs gas exchange, leading to hypoxia.
C. Hiccoughs: Not associated with hypoxia; they are an involuntary diaphragmatic spasm.
D. High altitude: Decreased atmospheric oxygen levels can result in hypoxia.
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