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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This choice is incorrect because slowing the rate to 50 mL/hr may not be enough to prevent cerebral edema, which is a common complication of head injury. Cerebral edema is a swelling of the brain tissue due to increased fluid accumulation. It can cause increased intracranial pressure (ICP), which can lead to brain damage or death. Therefore, the nurse should limit the fluid intake of the client with head injury to avoid worsening the condition.
Choice B Reason: This choice is incorrect because increasing the rate to 250 mL/hr may cause fluid overload, which can also increase the ICP and worsen the cerebral edema. Fluid overload is a condition in which the body has too much fluid, which can impair the function of the heart, lungs, and kidneys. Therefore, the nurse should avoid giving too much fluid to the client with head injury.
Choice C reason: Reducing the infusion to 20 mL/hr is excessively low and may cause hypotension or inadequate maintenance of vascular access and medication delivery. Such a drastic decrease could impair perfusion to injured brain tissue and is not an appropriate independent nursing action without a specific order.
Choice D reason: Maintaining the current prescribed infusion rate avoids abrupt volume shifts that could alter intracranial pressure. The nurse should monitor neurologic status and vital signs, ensure the IV is patent, and follow provider orders; only change the rate when clinically indicated or when directed by the prescriber.
Correct Answer is ["167 "]
Explanation
To calculate the dose of enoxaparin, follow these steps:
1) Convert the client's weight from pounds to kilograms:
245 lbs / 2.2046 (kg/lb) = 111.13 kg (rounded to the nearest whole number, it's 111 kg).
2) Multiply the weight in kilograms by the prescribed dose per kilogram:
111 kg x 1.5 mg/kg = 166.5 mg.
Round the answer to the nearest whole number, so the nurse should administer 167 mg per dose of enoxaparin every 12 hours to the client with a pulmonary embolism.
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