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. Use a 14-Fr catheter: This is the appropriate size for suctioning an adult to effectively remove thick secretions.
B. Use suction pressure between 120 and 160 mm Hg: This pressure is too high and may cause mucosal damage; 100 to 120 mm Hg is recommended for adults.
C. Use an 8-Fr catheter: This size is too small for effectively suctioning thick secretions in adults.
D. Use the catheter to suction the mouth and nasopharynx: Suctioning the mouth first contaminates the catheter, increasing the risk of infection in the nasopharynx.

A. Check for secretion clearance. B. Check the function of the suction catheter. C. Don sterile gloves. D. Adjust the suction to 120 to 150 mm Hg. E. Insert the catheter without suction. F. Apply intermittent suction while rotating the catheter G. Hyperoxygenate the client.

Correct Answer is B,C,D,G,E,F,A

Explanation

Check the function of the suction catheter: Ensures the catheter is functioning properly before starting the procedure.

Don sterile gloves: Maintains asepsis during the suctioning procedure.

Adjust the suction to 120 to 150 mm Hg: Proper suction pressure prevents mucosal trauma.

Hyperoxygenate the client: Prevents hypoxia during the suctioning process.

Insert the catheter without suction: Prevents trauma to mucosa by reducing suction on insertion.

Apply intermittent suction while rotating the catheter: Effectively clears secretions while minimizing tissue damage.

Check for secretion clearance: Ensures the airway is clear and the procedure was effective.

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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 nurse is nasopharyngeal suctioning an adult patient to remove thick secretions. The nurse will:

Correct Answer is A

Explanation

A nurse is preparing to suction the airway of a client who has a tracheostomy. Identify the sequence of actions the nurse should take after performing hand hygiene. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Correct Answer is B,C,D,G,E,F,A

Explanation

A nurse is reinforcing teaching with a client who is having difficulty using an incentive spirometer. Which of the following instructions should the nurse include in the teaching?

A nurse caring for a patient with a tracheostomy should determine whether the patient needs suctioning by:

A nurse is caring for a client who is experiencing respiratory distress. Which of the following positions should the nurse assist the client into?

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority?

Which is a function of the respiratory system?

A nurse is collecting data from a client who has a respiratory disorder and displays manifestations of hypoxia. Which of the following findings should the nurse expect?

A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following should the nurse do after noticing a rise in the water seal with client inspiration?

Which of the following is not considered an adventitious lung sound upon auscultation: