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. Pleural friction rub: An adventitious sound that occurs due to inflamed pleural surfaces rubbing against each other during respiration.
B. Rhonchi: A low-pitched, continuous adventitious lung sound typically caused by airway obstruction or secretions.
C. Stridor: A high-pitched adventitious sound caused by upper airway obstruction.
D. Vesicular: A normal breath sound heard over most of the lung fields, characterized by a soft, low-pitched rustling sound.
Correct Answer is C
Explanation
A. Bradypnea: Hypoxia typically leads to tachypnea as the body attempts to increase oxygen intake.
B. Pallor: While it can be a sign of poor perfusion, cyanosis is more closely associated with hypoxia.
C. Cyanosis: A late sign of severe hypoxia, indicating a lack of oxygen in the tissues.
D. Bradycardia: Hypoxia usually stimulates tachycardia as the body tries to compensate.
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