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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A Metoprolol works by blocking beta-adrenergic receptors, which can lead to bradycardia (slow heart rate) as a side effect. A heart rate of 48/min may indicate bradycardia, which can reduce cardiac output and potentially worsen symptoms in clients with heart failure.
B. Body temperature within the normal range does not indicate an adverse effect of metoprolol. Changes in temperature are not typically associated with this medication.
C. Respiratory rate within the normal range does not indicate an adverse effect of metoprolol. Respiratory changes are generally not associated with beta-blocker use.
D. Metoprolol can cause hypotension (low blood pressure) as a side effect, especially if the dosage is too high or if the client is dehydrated. However, a blood pressure of 138/76 mm Hg is within the normal range for an adult and does not necessarily indicate hypotension.
Correct Answer is D
Explanation
D. Morphine is effective in reducing anxiety due to its sedative and anxiolytic properties. Decreased anxiety can be an indication that morphine is effective in managing symptoms associated with acute heart failure, such as dyspnea and anxiety related to difficulty breathing.
A Morphine is a potent opioid analgesic that can depress the respiratory center, leading to decreased respiratory rate or even respiratory depression in some cases.
B. Vomiting after morphine administration does not indicate effectiveness of the medication in managing acute heart failure symptoms. It is rather a side effect that needs to be managed.
C. Decreased urinary output is not a sign of effectiveness in managing acute heart failure symptoms. It is an adverse effect that needs to be monitored and managed separately.
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