The nurse is performing hourly rounds on a patient with a chest tube attached to a 3-chamber water seal drainage system. The nurse observes constant bubbling in the water seal chamber. What action should the nurse take first?

Call the provider

Apply a sterile dressing to the chest tube insertion site.

Assess the chest tube connections

Place the patient on oxygen

Answer and Explanation

The Correct Answer is C

A. Call the provider: Notifying the provider may eventually be necessary, but immediate assessment is required first to determine the cause of constant bubbling. Calling the provider without assessing the system does not address the potential underlying problem.

B. Apply a sterile dressing to the chest tube insertion site: Applying a dressing is important for preventing infection but will not stop or explain constant bubbling in the water seal chamber. The priority is identifying whether the bubbling is due to an air leak.

C. Assess the chest tube connections: Constant bubbling in the water seal chamber usually indicates an air leak. The nurse should first inspect all tubing connections, insertion site, and the drainage system to locate and correct any leaks before notifying the provider or taking further action. Proper assessment ensures patient safety and prevents loss of negative pressure.

D. Place the patient on oxygen: Oxygen supplementation may be indicated for hypoxemia but does not address the cause of constant bubbling in the chest tube system. The immediate priority is identifying and correcting any mechanical or tubing-related issues.

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Correct Answer is C

Explanation

A. Administer sedatives: Sedation is important after intubation to ensure patient comfort and prevent agitation, but it is not the immediate priority. Confirming proper tube placement and ensuring effective ventilation must occur first to prevent hypoxia or accidental esophageal intubation.

B. Secure the tube: Securing the ETT prevents accidental displacement, which is essential for ongoing airway management. However, before securing, the nurse must first verify that the tube is correctly positioned in the trachea to ensure effective ventilation.

C. Auscultate lung sounds: The first action after ETT placement is to confirm correct placement by assessing bilateral breath sounds and observing for chest rise. This ensures that the tube is in the trachea and not the esophagus, preventing life-threatening hypoxia and guiding further interventions.

D. Draw an arterial blood gas (ABG): ABG analysis provides valuable information about oxygenation and ventilation status, but it is performed after confirming proper tube placement and establishing effective ventilation. Immediate verification of the airway takes priority over laboratory assessment.

A. Administer amiodarone 150 mg IV B. Begin transcutaneous pacing C. Begin cardioversion D. Administer nitroglycerine 5 mcg/min IV

Correct Answer is B

Explanation

A. Administer amiodarone 150 mg IV: Amiodarone is used to treat ventricular arrhythmias such as ventricular tachycardia or fibrillation. Second-degree Mobitz type II block is a conduction failure at the level of the His-Purkinje system, leading to dropped QRS complexes and bradycardia, not a tachyarrhythmia requiring antiarrhythmic therapy.

B. Begin transcutaneous pacing: Mobitz type II block is a high-grade AV block with a significant risk of progressing to complete heart block. The patient is hypotensive and symptomatic (confused, lethargic), indicating poor perfusion. Immediate transcutaneous pacing is recommended to maintain adequate heart rate and cardiac output until a more permanent solution, such as transvenous pacing, is established.

C. Begin cardioversion: Cardioversion is indicated for unstable tachyarrhythmias with a pulse, such as atrial fibrillation with rapid ventricular response or ventricular tachycardia with a pulse. This patient has a bradyarrhythmia due to AV block, so cardioversion would not correct the underlying conduction defect.

D. Administer nitroglycerine 5 mcg/min IV: Nitroglycerin reduces preload and can lower blood pressure. Given the patient’s hypotension (84/52 mmHg), administering nitroglycerin would worsen perfusion and does not address the underlying conduction abnormality causing the syncopal episode.

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The nurse is performing hourly rounds on a patient with a chest tube attached to a 3-chamber water seal drainage system. The nurse observes constant bubbling in the water seal chamber. What action should the nurse take first?

Nursing Test Bank

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