A nurse is caring for a client who has a chest tube in the pleural space. The nurse notices continuous bubbling in the water seal chamber of the client's drainage system. Which of the following actions should the nurse take?

Raise the drainage system to the client's chest level.

Clamp the tubing to check for air leaks.

Empty the collection chamber.

Gently squeeze the tubing to remove excess drainage.

Answer and Explanation

The Correct Answer is B

B. The appropriate action for a nurse to take would be to check for air leaks in the system. This can be done by clamping the tubing momentarily to see if the bubbling stops, which would suggest the presence of a leak.

A The drainage system should always be kept below the level of the chest and should not be raised or emptied unless specifically indicated.

C. Emptying the collection chamber is typically unnecessary unless it is nearing full capacity. Continuous bubbling in the water seal chamber does not indicate that the collection chamber needs immediate emptying.

D. Squeezing the tubing can disrupt the functioning of the drainage system and is not recommended. Drainage should flow passively into the collection chamber without external manipulation.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}

Explanation

The client is at risk for developing bleeding due to platelet count

Rationale:

The client's platelet count at the 3-month visit is 112,000/mm3, which is below the normal range (150,000 to 400,000/mm3). Platelets are crucial for blood clotting, and a low platelet count increases the risk of bleeding.

A. Diphenhydramine B. Flumazenil C. Calcium gluconate D. Naloxone

Correct Answer is D

Explanation

D. Naloxone competitively binds to opioid receptors, displacing opioids from these receptors and rapidly reversing their effects. It is the drug of choice for managing opioid-induced respiratory depression and is administered to restore adequate ventilation and prevent respiratory arrest.

A Diphenhydramine is an antihistamine with sedative properties. It is used primarily for allergic reactions and as a sleep aid. Diphenhydramine is not indicated for reversing respiratory depression caused by opioid overdose. It does not antagonize opioid receptors or reverse the effects of opioids.

B. Flumazenil is not effective in reversing respiratory depression caused by opioid overdose. It does not affect opioid receptors or reverse the respiratory depressant effects of opioids.

C. Calcium gluconate is a form of calcium used to treat hypocalcemia or to counteract the cardiac effects of hyperkalemia. It does not reverse opioid-induced respiratory depression. It is not indicated in this situation.

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A nurse is caring for a client who has a chest tube in the pleural space. The nurse notices continuous bubbling in the water seal chamber of the client's drainage system. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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