The nurse is assessing a patient with chest tubes connected to a drainage system. What should the first action be when the nurse observes excessive bubbling in the water seal chamber?

Place the head of the patient's bed flat.

Notify the healthcare provider.

Milk the chest tube.

Disconnect the system and get another.

Answer and Explanation

The Correct Answer is B

A. Place the head of the patient's bed flat: Positioning the patient flat does not address the underlying issue of excessive bubbling. This intervention has no effect on the integrity of the chest tube system or on resolving the possible air leak.

B. Notify the healthcare provider: Excessive bubbling in the water seal chamber usually indicates an air leak in the chest tube system or from the patient’s lung. Prompt notification of the healthcare provider ensures timely evaluation and correction of the problem to prevent complications.

C. Milk the chest tube: Milking or stripping chest tubes is not recommended because it can create high negative pressures and damage lung tissue. This action does not correct excessive bubbling and may worsen patient outcomes.

D. Disconnect the system and get another: Disconnecting the system increases the risk of introducing air into the pleural space, potentially leading to a tension pneumothorax. Replacing the system may be needed, but it should not be done before assessing and notifying the healthcare provider.

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Correct Answer is A

Explanation

A. Speaking in short phrases or sentences: This indicates severe dyspnea and increased work of breathing, suggesting the client may not be able to maintain adequate ventilation and oxygenation. It is a sign of respiratory distress and requires immediate intervention.

B. Distant heart sounds: While this may be present in COPD due to hyperinflation of the lungs, it is not immediately life-threatening and does not require urgent action compared to severe dyspnea.

C. Diminished lung sounds: This is common in COPD due to air trapping and hyperinflation but does not always indicate acute deterioration unless accompanied by other distress signs.

D. Pursed-lip breathing: This is actually a beneficial compensatory mechanism that helps keep airways open longer to improve carbon dioxide elimination and is not a sign of acute danger.

A. Scattered rhonchi and crackles with an elevated WBC count B. Clubbing of the fingers and polycythemia C. Copious amounts of rust-colored sputum with cyanosis D. Distended neck veins and dependent edema

Correct Answer is B

Explanation

A. Scattered rhonchi and crackles with an elevated WBC count: These findings suggest an acute respiratory infection or pneumonia, not chronic hypoxemia. Elevated WBC count points to infection rather than a long-term adaptation to COPD.

B. Clubbing of the fingers and polycythemia: These are expected in chronic hypoxemia. Clubbing results from prolonged low oxygen levels, while polycythemia develops as the body compensates by producing more red blood cells to increase oxygen-carrying capacity.

C. Copious amounts of rust-colored sputum with cyanosis: Rust-colored sputum is typically associated with bacterial pneumonia, particularly pneumococcal infection, not chronic hypoxemia. Cyanosis may occur, but the sputum description makes this finding less appropriate.

D. Distended neck veins and dependent edema: These findings are consistent with cor pulmonale or right-sided heart failure, a complication of COPD, but they are not the expected baseline findings of chronic hypoxemia itself.

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The nurse is assessing a patient with chest tubes connected to a drainage system. What should the first action be when the nurse observes excessive bubbling in the water seal chamber?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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