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 A
Explanation
A. Weight loss is not a common side effect of prednisone. Instead, prednisone often causes weight gain due to fluid retention and increased appetite.
B. Dry mouth can occur with prednisone use, although it is less common than other side effects.
C. Hyperglycemia is a common side effect. Corticosteroids like prednisone can increase blood glucose levels, which is particularly concerning for clients with diabetes.
D. Decreased wound healing is a known side effect. Prednisone suppresses the immune system and inflammatory response, leading to delayed tissue repair.
Correct Answer is D
Explanation
A. Hemoptysis (coughing up blood) is a known symptom of a pulmonary embolism (PE). It results from lung tissue damage due to obstructed blood flow.
B. Petechiae are not typically associated with a PE. They are more commonly linked to conditions such as thrombocytopenia or fat embolism syndrome.
C. Tachycardia is a common manifestation of a PE. The heart rate increases as a compensatory mechanism due to decreased oxygenation.
D. Facial weakness is not a typical sign of PE. It is more commonly associated with conditions like stroke or Bell's palsy.
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