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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. “I will rest my hand over my abdomen to create resistance.” This technique is used for diaphragmatic breathing exercises, not incentive spirometry. It does not help assess or improve lung expansion, which is the primary goal of using the incentive spirometer.
B. “I will lie on my back with my knees bent.” While lying down may be appropriate for some breathing exercises, the incentive spirometer is best used in a sitting or upright position. Sitting allows for maximal lung expansion and facilitates more effective use of the device.
C. “I will place the adapter on my finger to read my blood oxygen saturation level.” This describes the use of a pulse oximeter, not an incentive spirometer. The spirometer measures inspiratory volume, while pulse oximetry is used to monitor oxygen saturation.
D. "I will take in a deep breath and hold it before exhaling." The client should inhale slowly and deeply through the mouthpiece, hold the breath for several seconds to promote alveolar inflation, then exhale. This process helps prevent atelectasis and promotes lung expansion.
Correct Answer is B
Explanation
A. Inform the HCP:Notifying the healthcare provider is unnecessary in this case, as tidaling in the water seal chamber is an expected and normal finding. It indicates that the chest tube is patent and responding to changes in thoracic pressure during respiration.
B. Continue to monitor the client:Tidaling reflects normal movement of air and fluid in response to respiration, suggesting the chest tube is functioning correctly. The most appropriate action is to continue monitoring the client.
C. Reinforce the occlusive dressing:There is no indication that the dressing is loose or compromised. Without evidence of air leak or tube displacement, reinforcing the dressing is not necessary at this point.
D. Encourage the client to deep breathe:While deep breathing is important for lung expansion and preventing complications like atelectasis, it is not specifically indicated in response to the observation of tidaling.
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