Mrs. D is a 50 year old female admitted with a history of diabetes. Her vital signs are: T-101.9, HR= 110, RR= 30, BP=90/70. Labs reveal a glucose of 780.

Her ABG reveals:

pH 7.25

PaCO2 30

HCO3 22

What interventions should be included in her plan of care for this disorder?

K+ replacement, Diamox

sedatives or analgesics, breathe into a paper bag, mechanical ventilation to decrease rate

vigorous pulmonary toilet, antibiotics, diuretics, mechanical ventilation

IVF's, insulin, oxygen therapy

Answer and Explanation

The Correct Answer is D

Rationale:

A. Potassium replacement may be required later during insulin therapy, but Diamox (acetazolamide) is not indicated. Diamox is used for metabolic alkalosis or other unrelated conditions, not for diabetic ketoacidosis.

B. The client is hyperventilating to compensate for metabolic acidosis (Kussmaul respirations). Suppressing respirations would worsen acidosis and increase the risk of respiratory failure

C. These interventions are appropriate for pulmonary infections or fluid overload, not metabolic acidosis due to DKA.

D. The priority interventions for diabetic ketoacidosis include intravenous fluids to correct dehydration and improve perfusion, insulin therapy to reduce hyperglycemia and stop ketone production, and oxygen therapy if hypoxia is present. Electrolytes and cardiac monitoring are also important, but fluids, insulin, and oxygen are the immediate life-saving measures.

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Correct Answer is C

Explanation

Rationale:
A. The system is functioning normally is incorrect because normal function of a water-seal chamber includes tidaling with respiration (the water level rises and falls with breathing) and intermittent bubbling, usually only during suction. Constant bubbling in the water-seal chamber indicates a problem, not normal function.

B. The patient has a pneumothorax is incorrect because while a pneumothorax may have caused the chest tube placement, the presence of constant bubbling in the water-seal chamber specifically indicates an air leak in the system, not necessarily a new or persistent pneumothorax.

C. The system has an air leak is correct. Constant bubbling in the water-seal chamber indicates that air is escaping somewhere in the system, either from the patient’s pleural space (ongoing pneumothorax) or from a loose connection, crack, or defect in the tubing or drainage system. The nurse should inspect all connections, tubing, and insertion site to locate and correct the leak.

D. The chest tube is obstructed is incorrect because obstruction typically prevents fluid or air from moving through the system, which may result in no tidaling or reduced drainage, not constant bubbling.

A. Disconnect the chest tube from the drainage system during transport. B. Clamp the chest tube prior to transferring the client to a wheelchair. C. Empty the collection chamber prior to transport. D. Keep the drainage system below the level of the client's chest at all times.

Correct Answer is D

Explanation

Rationale:

A. Disconnect the chest tube from the drainage system during transport is incorrect because the chest tube must remain connected to the closed drainage system at all times. Disconnecting it would allow air to enter the pleural space, potentially causing a pneumothorax or tension pneumothorax. Maintaining a closed system is essential to preserve negative intrapleural pressure and prevent respiratory compromise.

B. Clamp the chest tube prior to transferring the client to a wheelchair is incorrect because routine clamping of a chest tube is contraindicated. Clamping can trap air in the pleural space and lead to a tension pneumothorax, which is life-threatening. Chest tubes are only clamped briefly for specific provider-ordered procedures, such as changing the drainage system or assessing for air leaks—not for transport.

C. Empty the collection chamber prior to transport is incorrect because emptying the drainage system is not routinely required before transport and may disrupt the sterile, closed system. Additionally, breaking the system increases infection risk and compromises accurate measurement of output. The drainage system is typically replaced—not emptied—when full, per facility protocol.

D. Keep the drainage system below the level of the client's chest at all times is correct. The drainage system must remain below chest level to prevent backflow of drainage or air into the pleural space. Gravity facilitates proper drainage, and elevating the system above chest level could allow fluid to reflux into the pleural cavity, increasing the risk of complications such as recurrent pneumothorax or infection.

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Mrs. D is a 50 year old female admitted with a history of diabetes. Her vital signs are: T-101.9, HR= 110, RR= 30, BP=90/70. Labs reveal a glucose of 780. Her ABG reveals: pH 7.25 PaCO2 30 HCO3 22 What interventions should be included in her plan of care for this disorder?

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Naxlex Comprehensive Predictor Exams

While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of the patient's closed chest-drainage system. What should the nurse conclude?

Correct Answer is C

Explanation

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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Mrs. D is a 50 year old female admitted with a history of diabetes. Her vital signs are: T-101.9, HR= 110, RR= 30, BP=90/70. Labs reveal a glucose of 780.

Her ABG reveals:

pH 7.25

PaCO2 30

HCO3 22

What interventions should be included in her plan of care for this disorder?