The nurse is caring for a patient who is 12 hours postoperative and has a chest tube to a disposable water-seal drainage system with suction.
The nurse should intervene for which of the following observations?
Continuous bubbling in the water-seal chamber.
Bloody drainage in the collection chamber.
Constant bubbling in the suction-control chamber.
Fluid-level fluctuations in the water-seal chamber.
The Correct Answer is A
Choice A rationale
Continuous bubbling in the water-seal chamber indicates a persistent air leak within the chest tube system. This is an abnormal finding as bubbling should only occur intermittently during expiration or coughing. A continuous air leak prevents the establishment of a negative intrapleural pressure, compromising the lung's ability to re-expand and can indicate a loose connection or a pleural tear.
Choice B rationale
Bloody drainage in the collection chamber is expected following chest surgery, especially in the immediate postoperative period. The amount and rate of drainage are the key assessments. The drainage should decrease over time.
Choice C rationale
Constant bubbling in the suction-control chamber is the expected and desired finding when suction is applied. This continuous bubbling confirms that the prescribed level of suction is being delivered to the pleural space, which is essential for removing air and fluid and promoting lung re-expansion.
Choice D rationale
Fluid-level fluctuations, also known as tidaling, in the water-seal chamber are a normal and expected finding. This movement reflects the changes in intrapleural pressure during respiration. The fluid level rises with inspiration and falls with expiration, indicating that the chest tube is patent and the lung is not fully re-expanded
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["150"]
Explanation
Step 1 is: 600 mg of Clindamycin in 50 mL is to run over 20 minutes.
Step 2 is: To find mL/hr, convert the minutes to hours by dividing 60 min by 20 min. 60 min ÷ 20 min = 3.
Step 3 is: Multiply the total volume of 50 mL by the conversion factor of 3. 50 mL × 3 = 150 mL. Final calculated answer is 150 mL/hr. *.
Correct Answer is ["A","B","E"]
Explanation
Paradoxical chest movement is the hallmark sign of flail chest. This occurs when two or more adjacent ribs are fractured in two or more places, creating a free-floating segment of the chest wall. During inspiration, the negative intrathoracic pressure causes the unstable segment to be pulled inward, while the rest of the chest expands. During expiration, the segment bulges outward, opposite the normal movement of the chest wall.
Choice B rationale
Flail chest involves significant trauma to the chest wall, including multiple rib fractures. This causes severe pleuritic pain, which is exacerbated by the movement of the chest wall during inspiration. The fractured ribs and associated soft tissue injury irritate the parietal pleura, leading to a sharp, stabbing pain that the patient describes as being worse with deep breaths.
Choice C rationale
Bradycardia is not a typical finding in flail chest. The patient's pain, respiratory distress, and potential hypoxemia trigger a sympathetic nervous system response. This compensatory mechanism leads to an increase in heart rate to maintain cardiac output and oxygen delivery to the tissues. Therefore, tachycardia is a more expected finding in a patient with flail chest. Normal heart rate is 60 to 100 beats per minute.
Choice D rationale
Jaundice, characterized by yellowing of the skin and eyes, is a result of hyperbilirubinemia, a condition associated with liver dysfunction, biliary obstruction, or excessive red blood cell destruction. It is not a direct finding or complication of flail chest, which is a musculoskeletal and respiratory injury. Jaundice would be a coincidental finding and not a direct sign.
Choice E rationale
Chest pain is a prominent and expected finding in a patient with flail chest. The pain is a direct result of the trauma, including multiple rib fractures and the associated soft tissue and muscle injury. The severity of the pain is often directly related to the number and location of the fractures and is a major contributor to the patient's respiratory distress. .
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