he nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action?

Change the chest tube drainage system.

Document the findings.

Check for an air leak.

Notify the health care provider.

Answer and Explanation

The Correct Answer is B

A. Change the chest tube drainage system: Changing the entire drainage system is not warranted for intermittent bubbling in the water seal chamber. This action is appropriate for malfunctioning systems or when there is a significant system compromise such as contamination or leakage.

B. Document the findings: Intermittent bubbling in the water seal chamber is an expected finding during active pneumothorax as air escapes from the pleural space. This indicates that the chest tube is functioning, and documenting the observation is the appropriate action.

C. Check for an air leak: Continuous, not intermittent, bubbling may indicate an air leak. Intermittent bubbling usually occurs during expiration or coughing and does not require investigation unless it becomes continuous or excessive.

D. Notify the health care provider: There is no immediate need to notify the provider for expected intermittent bubbling. This is a normal finding in some phases of pneumothorax resolution and does not indicate a complication requiring urgent intervention.

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Correct Answer is ["B","C","D"]

Explanation

A. Drink juices high in vitamin C: While vitamin C may help support immune function, it does not prevent the transmission of colds to others. This measure is more about personal health and has no direct effect on reducing contagion.

B. Cough into your elbow: Coughing into the elbow instead of the hands prevents the spread of respiratory droplets through touch, reducing the likelihood of contaminating surfaces and infecting others.

C. Wash hands frequently: Hand hygiene is one of the most effective ways to prevent the spread of respiratory viruses. Frequent handwashing helps remove viruses acquired from contaminated surfaces or respiratory secretions.

D. Cover the mouth and nose when sneezing: Covering the mouth and nose with a tissue or elbow during sneezing limits the dispersion of infectious droplets into the air, reducing transmission to others.

E. Use a saline nose spray frequently: Saline sprays may keep nasal passages moist and comfortable, but they do not reduce the risk of spreading infection to others. Their use is symptomatic, not preventive from a contagion standpoint.

A. "I will take a couple of doses of the leftover prednisone I have to decrease the swelling." B. "I should take my prescribed antibiotics three (3) times a day until I have taken them all." C. "I should be better with a couple of days of rest and some ibuprofen for the pain/fever." D. "I guess I will have to have my tonsils removed."

Correct Answer is B

Explanation

A. "I will take a couple of doses of the leftover prednisone I have to decrease the swelling.Using leftover medications, without a prescription is unsafe and inappropriate. Prednisone is not the first-line treatment and does not address the bacterial cause of the illness.

B. "I should take my prescribed antibiotics three (3) times a day until I have taken them all.” Completing the full course of prescribed antibiotics is essential to fully eradicate the infection, prevent complications like rheumatic fever, and reduce antibiotic resistance.

C. "I should be better with a couple of days of rest and some ibuprofen for the pain/fever."Rest and symptom relief do not treat the bacterial infection. Relying solely on supportive care without antibiotics can lead to prolonged illness and serious complications.

D. "I guess I will have to have my tonsils removed."Tonsillectomy is not a standard treatment for a single episode of strep throat. It may be considered only after recurrent infections or other complications, making this an inaccurate understanding of initial treatment.

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he nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action?

Nursing Test Bank

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