A nurse is assessing a client who has a chest tube connected to a water seal drainage system. The nurse observes continuous bubbling in the water seal chamber.

What does this finding indicate?

An air leak in the system

A normal functioning of the system

A need to empty the collection chamber

A need to clamp the chest tube

Answer and Explanation

The Correct Answer is A

An air leak in the system

Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the system, which can compromise the negative pressure needed for effective drainage of air and fluid from the pleural space. The nurse should locate the source of the air leak and take appropriate measures to correct it. Possible sources of air leak include loose connections, cracks or holes in the tubing or drainage container, or a leak in the lung tissue.

Incorrect options:

B) A normal functioning of the system - Intermittent bubbling in the water seal chamber during inspiration, expiration, or coughing is a normal finding that indicates that air is being removed from the pleural space. Continuous bubbling is abnormal and indicates an air leak.

C) A need to empty the collection chamber - The collection chamber is where fluid drained from the pleural space accumulates. The nurse should empty the collection chamber when it is full or according to facility policy. Bubbling in the collection chamber is not a normal finding and does not indicate a need to empty it.

D) A need to clamp the chest tube - Clamping the chest tube is not recommended unless ordered by the provider or necessary for changing the drainage system. Clamping the chest tube can cause a buildup of pressure in the pleural space and lead to complications such as tension pneumothorax.

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Correct Answer is C

Explanation

"I will avoid foods that are high in calcium."

Rationale: Hydrochlorothiazide is a thiazide diuretic that lowers blood pressure by increasing urine output and reducing fluid volume. However, it also causes increased excretion of potassium and magnesium, and decreased excretion of calcium and uric acid. Therefore, clients taking hydrochlorothiazide should eat more foods that are rich in potassium and magnesium, such as bananas, oranges, potatoes, spinach, nuts, and seeds; limit their intake of sodium and fluids to prevent fluid retention and edema; avoid foods that are high in uric acid, such as organ meats, shellfish, and alcohol; and monitor their serum calcium levels regularly. There is no need to avoid foods that are high in calcium, as hydrochlorothiazide does not increase calcium excretion.

Incorrect options:

A) "I will eat more foods that are rich in potassium." - This is a correct statement, as hydrochlorothiazide causes increased potassium excretion and can lead to hypokalemia if not supplemented.

B) "I will limit my intake of sodium and fluids." - This is a correct statement, as sodium and fluids can cause fluid retention and edema, which can increase blood pressure and counteract the effects of hydrochlorothiazide.

D) "I will drink alcohol in moderation." - This is a correct statement, as alcohol can increase uric acid levels and cause gout attacks in clients taking hydrochlorothiazide. Alcohol can also lower blood pressure and increase the risk of orthostatic hypotension.

A. Barrel-shaped chest B. Clubbing of the fingers C. Cyanosis of the lips and nail beds D. Wheezes on auscultation

Correct Answer is C

Explanation

Cyanosis of the lips and nail beds

Rationale: Cyanosis of the lips and nail beds indicates severe hypoxia and requires immediate intervention. The nurse should report this finding to the provider and administer oxygen as prescribed.

Incorrect options:

A) Barrel-shaped chest - This is a common finding in clients with COPD, due to the increased anteroposterior diameter of the chest caused by air trapping and hyperinflation of the lungs. It does not require immediate intervention.

B) Clubbing of the fingers - This is a sign of chronic hypoxia and is often seen in clients with COPD. It results from the proliferation of connective tissue at the base of the nails due to chronic low oxygen levels. It does not require immediate intervention.

D) Wheezes on auscultation - This is an expected finding in clients with COPD, due to the narrowing of the airways caused by inflammation, mucus production, and bronchospasm. It does not require immediate intervention.

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A nurse is assessing a client who has a chest tube connected to a water seal drainage system. The nurse observes continuous bubbling in the water seal chamber. What does this finding indicate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has hypertension is prescribed hydrochlorothiazide, a thiazide diuretic. The nurse teaches the client about dietary modifications while taking this medication. Which statement by the client indicates a need for further teaching?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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A nurse is assessing a client who has a chest tube connected to a water seal drainage system. The nurse observes continuous bubbling in the water seal chamber.

What does this finding indicate?