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. Headache is correct. Clients with obstructive sleep apnea often experience morning headaches due to intermittent hypoxia and hypercapnia caused by repeated episodes of airway obstruction during sleep.
B. Hypotension is incorrect. Obstructive sleep apnea is more commonly associated with hypertension rather than hypotension due to the body's stress response to low oxygen levels.
C. Constipation is not a common symptom of obstructive sleep apnea. Gastrointestinal symptoms are not typically associated with this condition.
D. Nausea is not a characteristic finding in obstructive sleep apnea. The primary symptoms involve respiratory and neurological effects due to oxygen deprivation during sleep.
Correct Answer is ["C","D","E"]
Explanation
A. Ascites is more commonly associated with right-sided heart failure. Right-sided failure leads to systemic congestion, causing fluid accumulation in the abdomen.
B. Edema in the legs and feet is a symptom of right-sided heart failure. Left-sided failure primarily affects the lungs, while right-sided failure leads to peripheral edema.
C. Crackles in the lungs are expected in left-sided heart failure. Pulmonary congestion results from blood backing up into the lungs, leading to fluid accumulation in the alveoli.
D. Confusion can occur due to decreased cardiac output and poor oxygenation to the brain. Clients with severe heart failure may experience cognitive changes or altered mental status.
E. Exertional dyspnea is a hallmark of left-sided heart failure. The inability of the left ventricle to pump effectively leads to pulmonary congestion, making breathing difficult during physical activity.
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