The nurse has assisted a health care provider (HCP) with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level (tidaling) in the water seal chamber after the tube is inserted. Based on this assessment finding, which action is most appropriate?

Inform the HCP.

Continue to monitor the client.

Reinforce the occlusive dressing.

Encourage the client to deep breathe

Answer and Explanation

The Correct Answer is B

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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Correct Answer is A

Explanation

A. Assess the posterior pharynx for active bleeding:Frequent throat clearing without reported pain after a tonsillectomy may indicate active bleeding, which can be life-threatening. Silent bleeding may drip down the throat and trigger subtle clearing rather than coughing or spitting, making visual inspection an immediate priority.

B. Place the client in the side lying position:Side-lying can help prevent aspiration if bleeding occurs, but it does not replace the need to directly assess for bleeding first. Positioning should follow an initial airway and bleeding assessment.

C. Give the client juice through a straw:Using a straw is discouraged after tonsillectomy because the suction motion can disrupt clots and provoke bleeding. Juice may be appropriate for hydration, but not with a straw and not before checking for bleeding.

D. Offer the client ice cream to coat the throat:Cold soft foods like ice cream may soothe the throat and reduce swelling, but this should not be the first action when silent bleeding is suspected. The priority is ensuring that no active bleeding is occurring before offering food.

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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The nurse has assisted a health care provider (HCP) with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level (tidaling) in the water seal chamber after the tube is inserted. Based on this assessment finding, which action is most appropriate?

Nursing Test Bank

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