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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. After administering a carbohydrate source (e.g., 6 oz of orange juice), the nurse should reassess the patient's blood glucose level. If the glucose is still below the target range (typically above 70 mg/dL), the next step is to give an additional 15 grams of carbohydrate to raise the blood sugar. This is a standard approach for mild to moderate hypoglycemia.
B. Giving 25 to 50 ml of 50% glucose IV is typically reserved for patients who are severely hypoglycemic and unable to swallow or are unresponsive. This method is appropriate when the patient cannot take oral glucose, but the client in this scenario is still conscious.
C. Administering 1 mg IM glucagon is used when a patient is unable to ingest glucose orally and is unresponsive or vomiting. It stimulates the liver to release stored glucose, but this is not necessary in a conscious patient who can swallow.
D. Administering a 5% to 10% dextrose infusion is typically used in more severe cases of hypoglycemia, especially when IV access is established, and the patient is unable to take oral glucose. This would not be necessary for a patient who can safely swallow.
Correct Answer is C
Explanation
A. The head of the bed should be elevated to at least 30-45 degrees to help prevent aspiration and reduce the risk of ventilator-associated pneumonia (VAP). Flat positioning increases the risk of aspiration and subsequent pneumonia.
B. Humidification is important for preventing drying of the respiratory passages but does not directly reduce the risk of VAP.
C. Turning the client every 2 hours (not just 4) is a key practice to prevent VAP by improving lung expansion, promoting drainage, and reducing the risk of ventilator-associated pneumonia.
D. Oral care, including brushing the teeth, should be done more frequently than every 12 hours. The current guidelines recommend brushing the client's teeth every 4-6 hours and using suctioning as needed to prevent oral bacterial buildup that can lead to VAP.
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