A nurse is caring for a patient with a chest tube and drainage system. The patient reports continuous bubbling in the water-seal chamber. Which of the following statements should the nurse make?

"This is a normal finding and does not require any intervention.".

"Let me clamp the tubing to see if the bubbling stops.".

"I'll apply an occlusive dressing to seal the wound site.".

"Notify the physician immediately; there might be an air leak.".

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Stating that continuous bubbling in the water-seal chamber is a normal finding and does not require any intervention is incorrect. Continuous bubbling indicates an air leak, and it requires prompt evaluation and intervention.

Choice B rationale:

Clamping the tubing to see if the bubbling stops is incorrect. Clamping the tubing would only be done to assess if the air leak is from the patient or the system, but it does not address the underlying issue.

Choice C rationale:

Applying an occlusive dressing to seal the wound site is incorrect. While dressing changes may be necessary to maintain a sterile environment, it will not resolve the air leak causing continuous bubbling.

Choice D rationale:

Notifying the physician immediately about the air leak is the appropriate nursing action. Continuous bubbling in the water-seal chamber suggests an air leak, which could compromise the effectiveness of the chest tube and require immediate medical attention.

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Correct Answer is B

Explanation

Choice A rationale:

Applying a pressure dressing to the wound site is not the priority intervention for a chest tube with signs of infection. The primary concern is to address the infection and prevent its spread.

Choice B rationale:

The nurse should prioritize obtaining cultures from the chest tube site to identify the causative organism responsible for the infection. This information will guide the selection of appropriate antibiotics to treat the infection effectively.

Choice C rationale:

Administering oxygen to improve ventilation may be beneficial for some patients, but it does not address the underlying infection. Oxygen therapy can support respiratory function but is not the priority intervention in this situation.

Choice D rationale:

Monitoring vital signs and oxygen saturation is essential but does not address the infection directly. Vital sign monitoring is ongoing, while obtaining cultures is a specific intervention targeted at the suspected infection.

A. "I haven't been eating much lately.". B. "I've been drinking a lot of water recently.". C. "I feel tired and lethargic all the time.". D. "My heart has been racing throughout the day.".

Correct Answer is A

Explanation

Choice A rationale:

The client's statement, "I haven't been eating much lately,”. supports the suspicion of hypoglycemia. When a person with diabetes does not eat enough, especially if they are taking insulin or certain oral medications, their blood sugar levels can drop, leading to hypoglycemia. The symptoms reported by the client, including feeling shaky, weak, and dizzy, are typical manifestations of low blood sugar.

Choice B rationale:

"I've been drinking a lot of water recently”. does not support the suspicion of hypoglycemia. This statement could indicate hyperglycemia instead, as excessive thirst (polydipsia) is a common symptom of high blood sugar in diabetes.

Choice C rationale:

"I feel tired and lethargic all the time”. is a non-specific symptom and does not directly indicate hypoglycemia. Fatigue can be caused by various factors, and in this case, there is no clear link to low blood sugar.

Choice D rationale:

"My heart has been racing throughout the day”. is also not indicative of hypoglycemia. Rapid heart rate (tachycardia) can have multiple underlying causes, and it is not a primary symptom of low blood sugar.

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A nurse is caring for a patient with a chest tube and drainage system. The patient reports continuous bubbling in the water-seal chamber. Which of the following statements should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a chest tube shows signs of infection, such as fever, chills, increased white blood cell count, and purulent drainage. What intervention should the nurse prioritize?

Correct Answer is B

Explanation

A client with diabetes reports feeling shaky, weak, and dizzy. The nurse suspects hypoglycemia. Which statement by the client supports this suspicion?

Correct Answer is A

Explanation

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