A nurse is caring for a client who is 12 hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations?

Constant bubbling in the suction-control chamber

Continuous bubbling in the water-seal chamber

Fluid-level fluctuations in the water-seal chamber

Bloody drainage in the collection chamber

Answer and Explanation

The Correct Answer is B

A. Constant bubbling in the suction-control chamber is normal as it indicates that the suction is active and functioning as intended. The chamber should have steady bubbling when suction is applied.
B. Continuous bubbling in the water-seal chamber is abnormal and indicates a potential air leak. The water-seal chamber should only bubble intermittently with respiratory effort or changes in pressure; constant bubbling suggests that air is being introduced into the system, which could indicate a malfunction or an air leak at the insertion site or along the tubing.
C. Fluid-level fluctuations in the water-seal chamber are normal and should be observed, especially with breathing. The fluid levels will rise with inspiration and fall with expiration, reflecting the changes in pressure within the pleural space.
D. Bloody drainage in the collection chamber is expected immediately after surgery, particularly in the early postoperative period. It may be a sign of surgical site drainage, but if it becomes excessive or persists, further assessment is required. However, a small amount of blood in the collection chamber initially is not abnormal.

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Correct Answer is C

Explanation

A. "You need the stool softener because it will be hard to defecate while you remain in bed.": This is not the most appropriate response. While immobility can make bowel movements more difficult, the primary concern following pituitary surgery is the avoidance of straining due to the potential for increased intracranial pressure (ICP). The emphasis should be on avoiding pressure on the surgical site rather than general difficulties from immobility.
B. "Any manipulation of the pituitary gland can cause difficulty in defecation, so stool softeners are important after your surgery.": This is misleading. While pituitary surgery may influence certain bodily functions, the most critical concern is preventing straining to avoid raising ICP. The focus should be on explaining the rationale for avoiding pressure on the surgical site.
C. "It is important you do not strain during bowel movements because this could result in increased pressure on your surgical site.": This is the correct response. Straining during bowel movements can increase ICP, which could potentially compromise healing or lead to complications after pituitary surgery. This explanation directly addresses the patient's safety and emphasizes the need for stool softeners to prevent straining.
D. "You can choose not to take the stool softener if you feel you do not need it.": This response is inappropriate because it does not emphasize the importance of preventing straining, which is a critical consideration after pituitary surgery. The nurse should provide education on the necessity of the stool softener to avoid complications rather than leaving the decision solely to the patient.

A. An increase in the secretion of both bile and pancreatic enzymes B. A decrease in the secretion of insulin caused by carbohydrates C. When the passage of food into the small intestine occurs too rapidly D. The inability to digest high-fat foods

Correct Answer is C

Explanation

A. Dumping syndrome is not related to the increased secretion of bile and pancreatic enzymes; it occurs when food passes too quickly from the stomach into the small intestine.
B. Dumping syndrome is not caused by a decrease in insulin secretion, but rather by rapid gastric emptying that can result in fluctuating blood sugar levels.
C. Dumping syndrome occurs when food moves too quickly from the stomach into the small intestine, causing a sudden release of insulin and other gastrointestinal symptoms, such as nausea, diarrhea, and dizziness.
D. While high-fat foods can be problematic for some gastric bypass patients, dumping syndrome is specifically related to rapid gastric emptying and not the inability to digest fat.

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A nurse is caring for a client who is 12 hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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