The nurse is assessing a patient who has a chest tube in place post CABG. The nurse observes that the drainage in the tubing rises and falls in rhythm with the patient's respirations. How should the nurse best respond to this assessment finding?
Document that the chest drainage system is operating as it is intended.
Encourage the patient to do deep breathing and coughing exercises.
Inform the physician promptly that there is an imminent leak in the drainage system.
Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes.
The Correct Answer is A
Rationale:
A. The tidaling of fluid in a chest tube water-seal chamber, which rises and falls with respiration, is a normal and expected finding. It indicates that the chest tube is patent and that intrathoracic pressure changes are being transmitted to the drainage system. This confirms proper function, and the nurse should document the finding.
B. While deep breathing and coughing exercises are generally encouraged post-CABG to prevent atelectasis and improve lung expansion, they are not directly indicated in response to normal tidaling. This action is supportive care but does not address the assessment finding itself.
C. A leak in the system would be indicated by continuous bubbling in the water-seal chamber, not by normal tidaling. Tidaling is expected and does not signify a leak. Informing the physician is unnecessary unless other abnormal findings occur, such as sudden cessation of tidaling or excessive bubbling.
D. Manipulating the chest tube in this manner is unsafe and unnecessary for normal tidaling. Repositioning should only be considered if the tube is malfunctioning or dislodged, which is not indicated here.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Prednisone is a corticosteroid used to suppress inflammation and immune responses in conditions such as asthma, autoimmune diseases, and allergic reactions. Prednisone does not have vasodilatory effects and does not interact with sildenafil in a way that could cause life-threatening complications. Therefore, taking sildenafil while on prednisone is not contraindicated.
B. Nitroglycerine is a nitrate commonly prescribed for angina or ischemic heart disease. Nitrates work by releasing nitric oxide, which causes vasodilation and decreased blood pressure. Sildenafil, a phosphodiesterase-5 (PDE5) inhibitor, also enhances nitric oxide-mediated vasodilation, particularly in the systemic and pulmonary circulation. When these two drugs are taken together, the effects add synergistically, which can lead to severe, life-threatening hypotension, syncope, myocardial ischemia, or even cardiac arrest. Because of this risk, the combination of sildenafil and nitrates is considered an absolute contraindication. Patients must be screened carefully for any nitrate use, including short-acting nitroglycerin for chest pain, before starting sildenafil.
C. Phenytoin is an anticonvulsant used to control seizures. It is metabolized by the liver’s cytochrome P450 system and can increase the metabolism of sildenafil, reducing its effectiveness. While this may require dose adjustment or timing considerations, it does not pose a life-threatening risk and is therefore not an absolute contraindication.
D. Metronidazole is an antibiotic used to treat anaerobic bacterial infections. It has no direct cardiovascular interactions with sildenafil and does not cause dangerous hypotension. There may be minor pharmacokinetic interactions in some cases, but these are not contraindications.
Correct Answer is C
Explanation
A. This is incorrect
B. This is incorrect
C. Step 1: Use the formula
Flow rate (mL/hr) = Total volume ÷ Time in hours
Step 2: Convert minutes to hours
30 minutes = 0.5 hour
Step 3: Insert known values
Total volume = 100 mL
Time = 0.5 hr
Flow rate = 100 ÷ 0.5
Flow rate = 200 mL/hr
Step 4: Match to the options
200 mL/hr
Final Answer: C. 200 mL/hr
D. This is incorrect
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