The client diagnosed with a right-sided pneumothorax had chest tubes inserted 2 hours ago. There is no fluctuation in the water-seal chamber of the chest drainage system. Which action should the nurse take first?

Assess the client's lung sounds.

Check for any kinks in the tubing.

Turn the client from side to side.

Ask the client to take deep breaths.

Answer and Explanation

The Correct Answer is B

A pneumothorax involves the accumulation of air in the pleural space, which disrupts the negative pressure required for lung expansion, leading to ipsilateral collapse. Management requires a closed-chest drainage system where the water-seal chamber acts as a one-way valve, allowing air to exit while preventing atmospheric reentry into the thoracic cavity.

Rationale:

A. Assessing lung sounds is a standard part of respiratory evaluation, but it is not the priority action when a mechanical obstruction is suspected. While decreased breath sounds are expected with a pneumothorax, the lack of tidaling suggests a physical blockage within the external drainage apparatus itself.

B. The nurse must first check for kinks in the tubing because sudden cessation of fluctuation, or tidaling, usually indicates an obstruction. Ensuring tubing patency is the most immediate, non-invasive step to resolve mechanical failure and maintain effective evacuation of air from the pleural interface.

C. Turning the client side to side can help mobilize fluid or air, but it should only be performed after ensuring the equipment integrity is intact. If a kink exists, repositioning the patient will not restore suction efficiency or tidaling, potentially delaying the correction of a simple mechanical kink.

D. Deep breathing exercises facilitate lung re-expansion and are used to check for tidaling once the system is known to be patent. However, if the tubing is occluded, deep breaths will not produce fluctuation in the chamber, making this step secondary to ensuring the circuit is clear.

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Correct Answer is A

Explanation

Geriatric fall risk is multifaceted, involving a decline in proprioceptive feedback and sensory integration that occurs with advanced age or chronic disease. Peripheral neuropathy, often characterized by paresthesia or anesthesia, prevents the individual from detecting foot placement or floor irregularities. This loss of sensory input severely impairs the compensatory postural adjustments required to maintain center of gravity during ambulation.

Rationale:

A. Decreased sensation in the lower extremities represents the greatest risk due to the loss of protective sensation and proprioception. Without tactile feedback, the client cannot accurately perceive the spatial orientation of their limbs, leading to trips and balance failures. This physiological deficit is a more significant predictor of falls than chronological age or the use of assistive devices.

B. A 73-year-old who engages in frequent walking excursions likely possesses higher musculoskeletal strength and better cardiovascular endurance. Regular physical activity actually serves as a protective factor against falls by improving coordination and maintaining muscle mass. This client is considered low risk compared to individuals with focal neurological or sensory deficits.

C. Using a cane indicates that the 80-year-old has recognized their stability needs and is using a compensatory aid to increase their base of support. Assistive devices, when used correctly, provide mechanical stability and reduce the likelihood of a fall occurring. While age is a factor, the proactive use of a cane makes this client safer than one with unmanaged sensory loss.

D. A 90-year-old who frequently requests assistance to change positions demonstrates high safety awareness and cognitive compliance with fall protocols. By seeking help rather than attempting unassisted transfers, the client effectively mitigates the risks associated with advanced frailty. Their dependence on staff for mobility actually acts as a safeguard against accidental falls during movement.

A. call any off-duty nurses to notify them to come in to work. B. Determine which clients could be discharged home immediately. C. Assess the staffing to determine which staff could be sent to the ED. D. Request all visitors to leave the hospital as soon as possible.

Correct Answer is B

Explanation

Disaster management in healthcare follows structured principles of surge capacity, resource reallocation, client prioritization, and rapid bed availability creation, focusing first on increasing treatment space and capacity for incoming mass casualty victims while maintaining safe ongoing inpatient care.

Rationale:

A. This action is premature because activating off-duty staff occurs after assessing internal capacity. Disaster response prioritizes immediate resource optimization within existing staffing before expanding workforce availability.

B. This action is correct because identifying clients who can be safely discharged immediately increases bed availability, supports surge capacity, and ensures rapid accommodation of incoming mass casualty victims from the bus accident.

C. This action is secondary because staffing adjustments to the ED are important but follow initial capacity creation steps. Bed availability must be addressed first to ensure proper patient placement before reallocating personnel.

D. This action is incorrect as visitor restriction may be part of disaster protocols but does not directly address immediate surge capacity needs. The priority is freeing inpatient beds to receive incoming critically injured clients.

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The client diagnosed with a right-sided pneumothorax had chest tubes inserted 2 hours ago. There is no fluctuation in the water-seal chamber of the chest drainage system. Which action should the nurse take first?

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