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 D

Explanation

A. Apply suction while advancing the catheter into the airway: This increases the risk of tissue trauma and should be avoided. Suction should only be applied during withdrawal.
B. Insert the non-lubricated catheter into the nasal passage: Lubrication is necessary to prevent nasal tissue trauma and facilitate smoother insertion.
C. Suction the nasotracheal passage after suctioning the mouth: Suctioning the mouth first introduces contamination into the sterile airway, increasing the risk of infection.
D. Hold the catheter with the dominant hand after donning sterile gloves: This technique maintains sterility and prevents contamination of the catheter during the procedure.

A. Assist the client to Fowler's position B. Promote removal of pulmonary secretions C. Increase the oxygen flow D. Obtain a specimen for arterial blood gases

Correct Answer is A

Explanation

A. Assist the client to Fowler's position: This position helps maximize lung expansion, making it easier for the client to breathe.
B. Promote removal of pulmonary secretions: Important but secondary to addressing immediate respiratory distress.
C. Increase the oxygen flow: This should only be done per provider order to avoid complications such as oxygen toxicity.
D. Obtain a specimen for arterial blood gases: This is a diagnostic step but not an immediate intervention for difficulty breathing.

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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

A patient requires suctioning via the nasotracheal route. In order to perform this procedure safely, the nurse should:

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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