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. Alcohol relaxes throat muscles, worsening obstructive sleep apnea (OSA). The client should be educated to avoid alcohol, even while using a CPAP machine.
B. CPAP improves sleep quality and reduces daytime sleepiness, making this statement accurate.
C. Weight loss can reduce the severity of OSA, and some clients may no longer need treatment after significant weight loss.
D. The CPAP machine functions by delivering continuous air pressure to keep the airway open, which is a correct statement.
Correct Answer is A
Explanation
A. Pleural effusion is a common complication of heart failure. Increased pressure in the pulmonary circulation can cause fluid to accumulate in the pleural space, leading to dyspnea and decreased lung expansion.
B. Infection is not a direct complication of heart failure. However, individuals with heart failure may have an increased risk of infections due to a weakened immune system.
C. Asthma is not a complication of heart failure. While both conditions can cause shortness of breath, asthma is a separate respiratory disorder.
D. Hemorrhage is not associated with heart failure. Instead, heart failure can lead to clotting abnormalities or increased bleeding risk if the client is on anticoagulants.
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