A nurse is caring for a client who has a closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration? Utilize image to see area that is being described.
Immediately notify the provider
Clamp the chest tube near the water seal
Continue to monitor the client
Reposition the client toward the left side
The Correct Answer is C
A. Immediately notify the provider . A rise in the water seal chamber with inspiration (tidaling) is a normal finding, indicating proper function of the chest drainage system. There is no need for immediate provider notification.
B. Clamp the chest tube near the water seal . Clamping the chest tube can lead to a tension pneumothorax by trapping air inside the pleural space. This action is only done temporarily for specific indications, such as assessing for an air leak or changing the drainage system.
C. Continue to monitor the client . Tidaling (fluctuation of water with inspiration and expiration) is expected in the water seal chamber. The nurse should continue to monitor for any sudden cessation of tidaling (which may indicate obstruction) or continuous bubbling (which may indicate an air leak).
D. Reposition the client toward the left side . Position changes do not affect normal tidaling in a functioning chest tube system. However, frequent repositioning is encouraged to promote lung expansion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Deep vein thrombosis is not a known risk factor for obstructive sleep apnea. Sleep apnea is primarily related to airway obstruction rather than circulatory issues.
B. Being female is incorrect. Obstructive sleep apnea is more common in males than females, although postmenopausal women have an increased risk.
C. Obesity is correct. Excess weight, particularly around the neck, increases the risk of airway obstruction during sleep, making obesity a major risk factor for obstructive sleep apnea.
D. Atherosclerosis is not a direct risk factor. However, untreated obstructive sleep apnea can contribute to cardiovascular issues, including hypertension and atherosclerosis.
Correct Answer is B
Explanation
A. Nitroglycerin is used in the acute phase of an MI to relieve chest pain by dilating coronary arteries. However, after the initial phase, it is not the primary medication for managing pain and anxiety.
B. Morphine is administered after the initial acute phase to manage pain and anxiety. It reduces myocardial oxygen demand, decreases pain perception, and provides sedation, which can help lower stress levels.
C. Aspirin is given in the acute phase to prevent further clot formation but does not address pain and anxiety.
D. Oxygen is administered in the acute phase if the client is hypoxic, but routine oxygen therapy is no longer recommended unless needed.
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