The nurse is caring for a patient with a chest tube connected to a water-seal drainage system. The nurse observes that the drainage in the chest tube drainage system has suddenly decreased. Which of the following actions should the nurse take first?

Change the chest tube drainage system

Increase the suction pressure on the chest tube drainage system

Assess the tubing of the chest tube and drainage system

Call the provider immediately to report the decrease in drainage

Answer and Explanation

The Correct Answer is C

A. Change the chest tube drainage system: Replacing the entire drainage system may be necessary if it is malfunctioning, but this is not the first action. Immediate assessment is required to determine the cause of the sudden decrease in drainage before taking corrective steps.

B. Increase the suction pressure on the chest tube drainage system: Adjusting suction without understanding the reason for decreased drainage could worsen the situation or create unnecessary negative pressure. Suction adjustments should only be made after identifying the underlying issue.

C. Assess the tubing of the chest tube and drainage system: The first action is to inspect the tubing for kinks, clots, disconnections, or obstructions, which are the most common causes of sudden decreased drainage. Ensuring the system is intact and functional preserves lung re-expansion and prevents complications.

D. Call the provider immediately to report the decrease in drainage: Reporting to the provider is important if a problem is identified, but the nurse must first assess and gather information about the situation. Immediate assessment provides critical data for accurate reporting and timely intervention.

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Correct Answer is D

Explanation

A. Prepare the patient for a transvenous pacemaker: Transvenous pacing is reserved for symptomatic bradycardia that is unresponsive to medications or when hemodynamic compromise occurs. Since this patient is alert, oriented, and hemodynamically stable, immediate pacing is not indicated.

B. Prepare the patient for cardioversion: Cardioversion is used for unstable tachyarrhythmias, not for bradycardia. Applying this intervention to a stable patient with sinus bradycardia would be inappropriate and potentially harmful.

C. Document that the patient is in normal sinus rhythm: Although sinus bradycardia may be normal for some patients (e.g., athletes), it is still important to notify the provider for further assessment and to determine if intervention or monitoring adjustments are needed. Documentation alone is insufficient.

D. Contact the provider: The patient’s heart rate is below normal, though currently stable. The nurse should notify the provider to report the bradycardia, allowing the provider to evaluate for possible causes, review medications, and determine if any interventions are necessary. This ensures safe, proactive management.

A. Assess the patient's blood pressure B. Set the pacer to 65 beats per minute C. Start chest compressions D. Prepare for cardioversion

Correct Answer is C

Explanation

A. Assess the patient's blood pressure: In ventricular fibrillation, the patient is pulseless and unresponsive, so assessing blood pressure will not provide meaningful information. Immediate life-saving interventions take priority over vital sign assessment.

B. Set the pacer to 65 beats per minute: Pacing is used for bradyarrhythmias with a perfusing rhythm, not for pulseless ventricular fibrillation. It cannot establish effective cardiac output in a chaotic ventricular rhythm.

C. Start chest compressions: After a defibrillation shock, if the patient remains in pulseless VF, high-quality CPR should be initiated immediately to maintain circulation to vital organs. Early chest compressions are critical for increasing the chances of return of spontaneous circulation (ROSC) and improving outcomes.

D. Prepare for cardioversion: Synchronized cardioversion is used for unstable rhythms with a pulse, such as atrial fibrillation or VT with a pulse. In pulseless VF, unsynchronized defibrillation and CPR are required, not cardioversion.

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The nurse is caring for a patient with a chest tube connected to a water-seal drainage system. The nurse observes that the drainage in the chest tube drainage system has suddenly decreased. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient and observes the following rhythm on the monitor (see image below or in the attachment for a 6-second rhythm strip). The patient is alert and oriented x3, has a blood pressure of 105/56 mmHg, and denies chest pain. What action should the nurse take first?

Correct Answer is D

Explanation

During a code blue, the nurse observes the following rhythm on the monitor (see below or in the attachment of a 6 second rhythm strip) following a defibrillation shock. What is the nurses' first action?

Correct Answer is C

Explanation

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