The nurse suspects which cause of increased bubbling in the water seal chamber of a patient's chest drainage unit?

The patient has a pleural friction rub.

The patient has an infection at the drainage site.

The patient has a bronchopleural leak.

The patient has complete lung re-expansion.

Answer and Explanation

The Correct Answer is C

A. A pleural friction rub occurs when the pleural surfaces rub against each other, usually due to inflammation, but it does not directly cause increased bubbling in the water seal chamber of a chest drainage unit.
B. An infection at the drainage site could lead to localized symptoms like redness or discharge, but it does not directly cause increased bubbling in the water seal chamber.
C. A bronchopleural leak is the most likely cause of increased bubbling in the water seal chamber. This occurs when there is an air leak between the lungs and pleural space, causing continuous air to enter the chest drainage system.
D. Complete lung re-expansion would not typically cause bubbling in the water seal chamber. Once the lung is fully re-expanded, bubbling should stop.

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Correct Answer is A

Explanation

A. A total laryngectomy involves the removal of the larynx, which can impact both the ability to smell and taste. This is due to the altered airflow and the loss of normal sensory processes. Explaining this to the patient is an appropriate response.
B. While offering to provide preferred foods may seem empathetic, it does not address the underlying issue, which is the loss of taste and smell due to the surgery.
C. Telling the client that hospital food is often tasteless does not address the patient's specific condition and may seem dismissive of their concerns.
D. While it might be helpful for the family to bring food, the nurse should first address the reason for the altered taste perception and educate the patient accordingly.

A. Shake the MDI prior to administration. B. Ask the client to inhale the medication quickly for 1 second. C. Wash the MDI canister in warm water after each use. D. Ask the client to hold their breath for 2 seconds after inhalation.

Correct Answer is A

Explanation

A. Shake the MDI prior to administration: This is the correct action. Shaking the MDI ensures that the medication is evenly mixed with the propellant, which is essential for delivering the correct dose. If the inhaler is not shaken, the medication may not be properly dispensed.
B. Ask the client to inhale the medication quickly for 1 second: This is incorrect. The client should inhale slowly and deeply to ensure the medication reaches the lower airways. A quick inhalation may not allow the medication to be delivered effectively, reducing its therapeutic effect.
C. Wash the MDI canister in warm water after each use: This is incorrect. The MDI canister itself should not be washed as it may damage the device. Only the mouthpiece should be cleaned according to the manufacturer's instructions. Overwashing the device can cause malfunctions.
D. Ask the client to hold their breath for 2 seconds after inhalation: This is too short. The client should hold their breath for about 10 seconds to allow the medication to fully reach the lungs and be absorbed. A brief hold, such as 2 seconds, may not be enough to maximize the medication's effectiveness.

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The nurse suspects which cause of increased bubbling in the water seal chamber of a patient's chest drainage unit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 1-day postoperative following a total laryngectomy and has begun a soft diet. The client is not eating well and tells the nurse that the hospital food has no taste. Which of the following responses is appropriate for the nurse to make?

Correct Answer is A

Explanation

A nurse is preparing to administer a metered dose inhaler (MDI) medication to a client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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