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 A

Explanation

A) Taping all connections within the system. Taping all connections helps prevent air leaks, which can compromise the function of the chest drainage system.
B) Turning on suction to 35 cm. Suction levels are typically set between 10 to 20 cm of water pressure. 35 cm is excessive and may cause lung tissue damage.
C) Keeping the system at the level of the patient's chest. The drainage system should always be kept below the level of the chest to promote gravity drainage and prevent backflow.
D) Looping the tubing between the mattress and the bed rail to minimize length. Tubing should not be looped or kinked, as this can obstruct drainage and compromise system function.

A. sitting upright and forward with arms supported on an over the bed table B. semi-Fowler's position with a single pillow behind the head C. high Fowler's position without a pillow behind the head D. right lateral with the head of the bed elevated 45 degrees.

Correct Answer is A

Explanation

A. Sitting upright and forward with arms supported on an over-the-bed table: This tripod position allows for maximum lung expansion by reducing pressure on the diaphragm and improving airflow, especially for patients with chronic obstructive pulmonary disease (COPD).
B. Semi-Fowler's position with a single pillow behind the head: This position does not optimize lung expansion as well as the tripod position.
C. High Fowler's position without a pillow behind the head: Although better than lying flat, this position lacks arm support, which helps in leveraging accessory muscles for breathing.
D. Right lateral with the head of the bed elevated 45 degrees: This position is not beneficial for promoting effective lung expansion in patients with emphysema.

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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:

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Naxlex Comprehensive Predictor Exams

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