A nurse in the recovery room is assessing a client who has a new chest tube. The nurse finds that the water seal is no longer tidaling. The nurse should identify the finding as resulting from which of the following?

An air leak noted at the insertion site.

The tubing may be kinked.

Water needs to be added to the suction-control chamber.

The suction is set too low.

Answer and Explanation

The Correct Answer is B

A. An air leak noted at the insertion site would result in continuous bubbling in the water seal chamber, not the absence of tidaling.

B. If the tubing is kinked or obstructed, it can prevent the movement of air in and out of the water seal chamber, leading to the absence of tidaling.

C. If water needs to be added to the suction-control chamber, this would affect the level of suction, not the tidaling in the water seal chamber.

D. If the suction is set too low, it would not necessarily affect the tidaling in the water seal chamber; instead, it would result in inadequate drainage or lack of suction.

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Correct Answer is A

Explanation

A. Monitor for abdominal ascites - Ascites is a common complication of cirrhosis due to portal hypertension and decreased albumin production. Monitoring for abdominal distention and fluid

accumulation is essential for assessing the progression of cirrhosis and implementing appropriate interventions.

B. Implement a low-carbohydrate diet - While dietary modifications may be necessary for clients with cirrhosis, such as reducing sodium intake, implementing a low-carbohydrate diet is not typically a primary intervention for cirrhosis.

C. Review serum amylase levels - Serum amylase levels are typically assessed to diagnose pancreatitis, which is not directly related to cirrhosis unless complications such as alcoholic pancreatitis are present.

D. Place warm compresses on areas of pruritus - Pruritus (itching) is a common symptom of liver disease, including cirrhosis, due to bile salt accumulation. While warm compresses may provide

temporary relief, they do not address the underlying cause of pruritus in cirrhosis.

A. "Notify your provider if you experience muscle weakness." B. "Report a weight gain of one-half pound per day." C. "Expect this medication to increase your blood pressure." D. "You will need to take a diuretic while taking this medication."

Correct Answer is A

Explanation

A. "Notify your provider if you experience muscle weakness." - Muscle weakness can be a sign of digoxin toxicity and should be reported to the provider immediately.

B. "Report a weight gain of one-half pound per day." - While weight gain can indicate fluid retention, it is not a specific symptom of digoxin toxicity.

C. "Expect this medication to increase your blood pressure." - Digoxin is not typically associated with increasing blood pressure.

D. "You will need to take a diuretic while taking this medication." - Diuretics are not typically required with digoxin unless there are specific indications for their use.

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A nurse in the recovery room is assessing a client who has a new chest tube. The nurse finds that the water seal is no longer tidaling. The nurse should identify the finding as resulting from which of the following?

Nursing Test Bank

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