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 ["A"]
Explanation
A. Incomplete expirations: Age-related decreased lung elasticity impairs full expiration, trapping air in the lungs.
B. Decreased oxygen saturation: Age-related changes in lung tissue reduce gas exchange efficiency.
C. Impaired cilia: Decreased ciliary function reduces the ability to clear mucus and pathogens from the airway.
D. Increased elasticity in thorax and respiratory tissues: Elasticity decreases with aging, reducing lung compliance.
Correct Answer is D
Explanation
A) "It delivers a specific concentration of oxygen constantly." A nasal cannula does not provide a constant or precise concentration of oxygen, as it is influenced by the client's breathing pattern.
B) "It allows you to remove it for a while when it gets uncomfortable." Removing the nasal cannula intermittently may disrupt oxygen therapy and decrease oxygen saturation.
C) "It delivers the highest concentration of oxygen possible." A nasal cannula delivers low-flow oxygen and does not provide the highest possible oxygen concentration.
D) "It delivers the low concentration of oxygen you need." A nasal cannula is designed for clients who need a low concentration of oxygen, typically between 1 to 6 liters per minute.
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