A nurse is assessing a client with a chest tube and observes the water level in the water seal bubbling as the client breathes. How should the nurse best respond to this assessment finding?
Inform the health care provider that there is a probable leak in the drainage system.
Encourage the client to breathe deeply so the water seal will stabilize.
Inform the health care provider that the client is ready to have the chest tube removed.
Document that the chest drainage system is functioning as intended.
The Correct Answer is D
A. Inform the health care provider that there is a probable leak in the drainage system: Bubbling in the water seal chamber of a chest drainage system during client breathing is an expected finding and indicates air movement in and out of the pleural space. It does not necessarily indicate a leak in the drainage system. Documenting the observation and assessing the client for other signs of complications would be appropriate before informing the healthcare provider.
B. Encourage the client to breathe deeply so the water seal will stabilize: Deep breathing by the client will not stabilize the water seal. The bubbling occurs due to air movement in and out of the pleural space during respiration and is a normal finding.
C. Inform the health care provider that the client is ready to have the chest tube removed: Bubbling in the water seal chamber does not necessarily indicate that the client is ready to have the chest tube removed. The decision to remove a chest tube is based on various factors, including the client's clinical status and resolution of the underlying condition requiring chest drainage.
D. Document that the chest drainage system is functioning as intended: Bubbling in the water seal chamber during client breathing indicates that the chest drainage system is functioning as intended. It is an expected finding and does not typically require intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Manage the emotions: Managing emotions is an important aspect of conflict resolution, but it typically occurs after the problem has been clarified and during the negotiation process to promote constructive dialogue and prevent escalation of conflict.
B. Breaking the ground rules: Breaking the ground rules refers to violating established guidelines or principles for effective communication and negotiation. This step is not evident in the scenario described.
C. Disregard the conflict: Disregarding the conflict would involve ignoring or avoiding addressing the issues altogether, which is not an appropriate approach to conflict resolution. The scenario indicates that the nurse manager is actively engaged in addressing the conflict.
D. Clarify the problem: In negotiation, clarifying the problem involves identifying and defining the underlying issues or concerns contributing to the conflict. Creating a list of main issues helps ensure that all parties have a clear understanding of what needs to be addressed and provides a foundation for developing potential solutions.
Correct Answer is "{\"xRanges\":[104.2578125,134.2578125],\"yRanges\":[114.30078125,144.30078125]}"
Explanation
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