The nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly?
Equal amount of fluid drainage in each collection chamber
Fluctuation of the fluid level within the water seal chamber
Continuous bubbling within the water seal chamber
Absence of fluid in the drainage tubing
The Correct Answer is B
Choice A Reason: Equal amount of fluid drainage in each collection chamber is not a sign of proper chest tube function. The amount of fluid drainage depends on the type and extent of the client's injury or surgery, and may vary from one chamber to another.
Choice B Reason: Fluctuation of the fluid level in the water seal chamber (tidaling) indicates that the chest tube is functioning properly. This fluctuation corresponds with the client's respirations and shows that air or fluid is being effectively removed from the pleural space.
Choice C Reason:Continuous bubbling within the water seal chamber: Continuous bubbling in the water seal chamber indicates an air leak, which is not normal unless the client has a pneumothorax and air is being evacuated. Otherwise, it suggests a problem with the system.
Choice D Reason: Absence of fluid in the drainage tubing is not a sign of proper chest tube function. It may indicate that the chest tube is obstructed, kinked, or clamped, or that the suction is not working properly. The nurse should assess and troubleshoot the chest tube system.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because respiratory alkalosis is characterized by a high pH and a low PaCO2, indicating that the client is hyperventilating and losing too much carbon dioxide.
Choice B Reason: This is incorrect because metabolic acidosis is characterized by a low pH and a low bicarbonate level, indicating that the client has an excess of metabolic acids or a loss of base.
Choice C Reason: This is incorrect because metabolic alkalosis is characterized by a high pH and a high bicarbonate level, indicating that the client has an excess of base or a loss of metabolic acids.
Choice D Reason: This is correct because respiratory acidosis is characterized by a low pH and a high PaCO2, indicating that the client is hypoventilating and retaining too much carbon dioxide.
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because a thrombotic stroke is caused by a clot that forms in a cerebral artery, usually due to atherosclerosis. It typically occurs gradually and does not cause a sudden, severe headache or seizure.
Choice B Reason: This is incorrect because an embolic stroke is caused by a clot that travels from another part of the body, such as the heart, to a cerebral artery. It usually occurs abruptly and does not cause vomiting or fever.
Choice C Reason: This is incorrect because a transient ischemic atack (TIA) is caused by a temporary interruption of blood flow to a part of the brain. It usually lasts less than an hour and does not cause permanent brain damage or loss of consciousness.
Choice D Reason: This is correct because a hemorrhagic stroke is caused by a rupture of a blood vessel in the brain, resulting in bleeding into the brain tissue or the subarachnoid space. It usually causes a sudden, severe headache, vomiting, seizure, and loss of consciousness. It can also cause elevated blood pressure, fever, and increased intracranial pressure.
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