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 D
Explanation
A. A balloon inflation within the artery describes percutaneous coronary intervention (PCI) or angioplasty, not CABG.
B. A medication to dissolve a blood clot refers to thrombolytic therapy, which is not part of a CABG procedure.
C. Injecting dye to outline heart vessels describes a coronary angiogram, which is a diagnostic procedure but not a treatment.
D. CABG involves using a healthy artery or vein to bypass the blocked portion of a coronary artery, restoring proper blood flow to the heart muscle.
Correct Answer is C
Explanation
A. Hypertension is not a direct risk factor for COPD. However, COPD and hypertension can coexist, especially in smokers.
B. Being male was once associated with a higher COPD prevalence, but COPD affects both sexes, especially as smoking habits have become more equal.
C. Alpha-1 Antitrypsin (AAT) deficiency is correct. AAT deficiency is a genetic disorder that leads to early-onset emphysema, even in non-smokers. It impairs the lungs' ability to protect themselves from enzymatic damage.
D. History of pulmonary embolism is not a primary risk factor for COPD, though lung damage from recurrent emboli can contribute to respiratory issues.
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