A nurse is assessing a client who has a chest tube with a water seal drainage system.
Upon assessment, the nurse notes tidaling in the water seal.
Which of the following is an explanation for the tidaling?
The lung has re-expanded.
There is a loop of tubing below the drainage system.
The system is working properly.
The tubing is partially obstructed by clots.
The Correct Answer is C
The correct answer is Choice C, the system is working properly.
Choice A rationale: The lung has re-expanded is incorrect. If the lung has re-expanded, there would be no tidaling in the water seal chamber, as the pleural space would be restored to its normal negative pressure. Tidaling indicates that there is still air or fluid in the pleural space that needs to be drained
Choice B rationale: There is a loop of tubing below the drainage system is incorrect. A loop of tubing below the drainage system would not cause tidaling in the water seal chamber, but it could cause fluid accumulation in the tubing, which could impair the drainage and increase the risk of infection. The tubing should be straight and free of kinks or loops
Choice C rationale: The system is working properly is correct. Tidaling in the water seal chamber means that the water level rises and falls with the patient’s respirations. This is normal and expected, as it indicates that the chest tube is patent and connected to the pleural space, and that the drainage system is airtight and preventing air or fluid from entering the pleural space. Tidaling should stop when the lung is fully re-expanded or the chest tube is clamped
Choice D rationale: The tubing is partially obstructed by clots is incorrect. If the tubing is partially obstructed by clots, there would be no tidaling in the water seal chamber, as the chest tube would not be able to drain the air or fluid from the pleural space. The water level in the water seal chamber would be stagnant, and the patient may experience respiratory distress. The tubing should be checked regularly for clots and milked gently if needed
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Recent myocardial infarction is not a contraindication for warfarin administration. Warfarin is often prescribed for patients with a history of myocardial infarction to prevent clot formation and reduce the risk of stroke.
Choice B rationale:
Recent eye surgery is a contraindication for the administration of warfarin. Warfarin can increase the risk of bleeding, which is particularly concerning after eye surgery due to the delicate nature of ocular tissues. Using anticoagulants in this scenario can lead to severe complications, including vision loss.
Choice C rationale:
Thrombophlebitis, inflammation of a vein with clot formation, is not a contraindication for warfarin administration. In fact, anticoagulants like warfarin are commonly prescribed to prevent the extension of clots and reduce the risk of complications associated with thrombophlebitis.
Choice D rationale:
Breast cancer is not a direct contraindication for warfarin administration. However, the decision to use anticoagulants in patients with a history of breast cancer should be made carefully, considering individual factors such as the stage of cancer, ongoing treatment, and overall risk of thromboembolic events.
Correct Answer is A
Explanation
Choice A rationale:
Glargine insulin is a long-acting insulin that provides a basal level of insulin over 24 hours. It is suitable for managing blood glucose levels in clients with diabetes mellitus who require a long-acting insulin to maintain glycemic control throughout the day.
Choice B rationale:
NPH insulin is an intermediate-acting insulin that lasts for about 12-16 hours. While it can be used for blood glucose management, it is not the best choice for a client needing long-acting insulin coverage throughout the day.
Choice C rationale:
Insulin aspart is a rapid-acting insulin used to control postprandial glucose levels. It acts quickly to lower blood sugar after meals and is not suitable for long-acting coverage.
Choice D rationale:
Regular insulin, also known as short-acting insulin, is used to control blood glucose levels during meals. It has a faster onset of action compared to long-acting insulins and is not appropriate for managing basal insulin needs over an entire day.
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