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 A
Explanation
Choice A Reason: This is correct because a pulmonary artery catheter is a device that measures the pressures and flows in the heart and lungs, such as the pulmonary artery pressure, the pulmonary artery wedge pressure, the cardiac output, and the mixed venous oxygen saturation. These parameters reflect the hemodynamic status of the client, which is the balance between the cardiac output and the systemic vascular resistance.
Choice B Reason: This is incorrect because a pulmonary artery catheter does not measure spinal cord perfusion, which is the blood flow to the spinal cord. Spinal cord perfusion can be affected by spinal cord injury, spinal anesthesia, or spinal surgery.
Choice C Reason: This is incorrect because a pulmonary artery catheter does not measure renal function, which is the ability of the kidneys to filter waste products and maintain fluid and electrolyte balance. Renal function can be assessed by urine output, blood urea nitrogen, creatinine, and glomerular filtration rate.
Choice D Reason: This is incorrect because a pulmonary artery catheter does not measure intracranial pressure, which is the pressure inside the skull. Intracranial pressure can be increased by brain injury, stroke, tumor, infection, or hydrocephalus.
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because fluid overload is a condition of excess fluid volume in the body. A client who has fluid overload is more likely to have a high CVP, which indicates increased pressure in the right atrium and vena cava.
Choice B Reason: This is incorrect because an intracardiac shunt is a condition of abnormal blood flow between the chambers of the heart. A client who has an intracardiac shunt may have a normal or high CVP, depending on the direction and magnitude of the shunt.
Choice C Reason: This is correct because hypovolemia is a condition of low fluid volume in the body. A client who has hypovolemia is more likely to have a low CVP, which indicates decreased pressure in the right atrium and vena cava.
Choice D Reason: This is incorrect because left ventricular failure is a condition of impaired pumping function of the left ventricle. A client who has left ventricular failure may have a normal or high CVP, depending on the degree of backward failure and pulmonary congestion.
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