A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?

Continue to monitor the client's respiratory status.

Check the suction control outlet on the wall.

Clamp the chest tube.

Check the tubing connections for leaks.

Answer and Explanation

The Correct Answer is A

Choice A Reason: This choice is correct because slow, steady bubbling in the suction control chamber indicates that the suction is working properly and maintaining a negative pressure in the pleural space. The nurse should continue to monitor the client's respiratory status, such as breath sounds, oxygen saturation, and respiratory rate, to assess the eﬀectiveness of the chest drainage system.

Choice B Reason: This choice is incorrect because checking the suction control outlet on the wall is not necessary unless there is no bubbling in the suction control chamber, which would indicate a problem with the suction source or setting. The nurse should ensure that the suction control outlet is set at the prescribed level, usually between 10 and 20 cm H2O.

Choice C Reason: This choice is incorrect because clamping the chest tube is not indicated unless there is a leak in the system or the chest drainage unit needs to be changed. Clamping the chest tube may cause a buildup of air or ﬂuid in the pleural space, which can lead to tension pneumothorax or pleural eﬀusion.

Choice D Reason: This choice is incorrect because checking the tubing connections for leaks is not necessary unless there is continuous bubbling in the water seal chamber, which would indicate an air leak in the system. The nurse should ensure that all tubing connections are tight and secure, and tape any loose connections.

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Correct Answer is A

Explanation

Choice A Reason: This choice is correct because respiratory acidosis is a condition in which the lungs cannot eliminate enough carbon dioxide (CO2) from the blood, resulting in a high level of CO2 (PaCO2) and a low level of pH. A normal PaCO2 range is 35 to 45 mm Hg, so a value of 50 mm Hg indicates respiratory acidosis.

Choice B Reason: This choice is incorrect because HCO3 (bicarbonate) is a base that helps to buﬀer the excess acid in the blood. In respiratory acidosis, the kidneys try to compensate by retaining more HCO3 and excreting more hydrogen ions. Therefore, a high level of HCO3 (above 26 mEq/L) would indicate a chronic or compensated respiratory acidosis, not an acute or uncompensated one.

Choice C Reason: This choice is incorrect because pH is a measure of the acidity or alkalinity of the blood. A normal pH range is 7.35 to 7.45, so a value of 7.45 indicates a neutral or slightly alkaline blood, not an acidic one. A low pH (below 7.35) would indicate respiratory acidosis.

Choice D Reason: This choice is incorrect because potassium is an electrolyte that helps to regulate the nerve and muscle function, as well as the ﬂuid balance in the body. In respiratory acidosis, the increased hydrogen ions in the blood may shift into the cells in exchange for potassium, resulting in a high level of potassium (hyperkalemia).

Therefore, a low level of potassium (below 3.5 mEq/L) would indicate hypokalemia, not respiratory acidosis.

A. Use log rolling to reposition the client. B. Place a warming blanket on the client. C. Instruct the client to cough and deep breathe. D. Place the client in a supine position.

Correct Answer is A

Explanation

Choice A Reason: This is correct because using log rolling to reposition the client helps maintain the alignment of the head and neck, which prevents further increases in ICP.

Choice B Reason: This is incorrect because placing a warming blanket on the client can cause vasodilation and increase cerebral blood ﬂow, which can raise ICP.

Choice C Reason: This is incorrect because instructing the client to cough and deep breathe can increase intrathoracic pressure and impede venous return, which can elevate ICP.

Choice D Reason: This is incorrect because placing the client in a supine position can decrease cerebral perfusion pressure and increase ICP. The client should be placed in a semi-Fowler's position with the head elevated at 30 degrees.

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A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?

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