The nurse would check for leaks in the chest tube and water seal system when:
there is continuous bubbling in the water-seal chamber.
the water levels in the water-seal chamber and suction chambers are decreased.
fluid in the water-seal chamber fluctuates with the client's breathing.
there is constant bubbling in the suction-control chamber.
The Correct Answer is A
A. There is continuous bubbling in the water-seal chamber: Continuous bubbling in the water-seal chamber suggests a potential air leak in the system, which needs to be investigated. The water-seal chamber is designed to prevent backflow of air into the pleural space, and persistent bubbling typically indicates that air is escaping from the pleural cavity or there is a problem with the tubing or chest tube placement. This is the first sign that the system may not be sealed properly and should be checked for leaks.
B. The water levels in the water-seal chamber and suction chambers are decreased: Decreased water levels in both the water-seal and suction chambers may be indicative of fluid loss or evaporation, but it does not necessarily point to a leak. In the case of a chest tube, water levels may also drop due to suction pressure or gradual evaporation, which would need to be adjusted or monitored. While this should be addressed, it is not an immediate cause for suspicion of an air leak in the system.
C. Fluid in the water-seal chamber fluctuates with the client's breathing: The fluctuation (also known as "tidaling") in the water-seal chamber is a normal finding that occurs when the client breathes in and out. It reflects the pressure changes in the pleural cavity during respiration. The absence of tidaling might indicate that the lung has re-expanded or that there is a blockage in the tubing. While tidaling is a normal occurrence, the absence or abnormality of this fluctuation would require further assessment but not for an air leak.
D. There is constant bubbling in the suction-control chamber: Constant bubbling in the suction-control chamber generally indicates that suction is appropriately applied to the system. However, if there is continuous bubbling in this chamber, it is typically related to the level of suction being applied, not an air leak. This is a normal occurrence and does not require checking for leaks in the system unless suction pressure is too high or low for optimal functioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["3.9"]
Explanation
Step-by-Step Solution:
Convert the toddler's weight from pounds to kilograms.
1 pound is =0.453592 kilograms.
So, 26 pounds = 26 x 0.453592 = 11.793592 kilograms.
Calculate the total daily dose of prednisolone.
The prescribed dose is 2 mg/kg/day.
The toddler weighs 11.793592 kg.
The total daily dose = 2 mg/kg/day x 11.793592 kg = 23.587184 mg/day.
Determine the dose per administration.
The total daily dose is divided into two equal doses (every 12 hours).
The dose per administration = 23.587184 mg/day / 2 = 11.793592 mg per dose.
Calculate the volume of prednisolone syrup to administer.
The available prednisolone syrup is 15 mg/5 ml.
We need to administer 11.793592 mg per dose.
To find the volume, we can set up a proportion:
15 mg / 5 ml = 11.793592 mg / x ml
Cross-multiplying:
15x = 5 x 11.793592
Solving for x:
x = (5 x 11.793592) / 15 = 3.931197 ml
Round the answer to the nearest tenth.
3.9 ml.
Correct Answer is B
Explanation
A) Encouraging the client to cough and deep breathe every two hours:
Encouraging the client to cough and deep breathe is an important nursing intervention for clients with a chest tube. This helps promote lung expansion, prevent atelectasis, and improve respiratory function. It also helps to clear secretions that may accumulate in the lungs. Therefore, this practice is appropriate and beneficial for the client.
B) Stripping the chest tube to dislodge any blood clots:
Stripping the chest tube, which involves forcibly pulling or pinching the tubing to remove clots, is an unsafe and outdated practice. It can create a dangerous increase in intrathoracic pressure, which may lead to tension pneumothorax, as well as injury to the lung tissue. Instead, the nurse should focus on gently milking the chest tube if necessary (if prescribed by the healthcare provider) or ensure that any blood clots are properly managed by the physician. Stripping or clamping the tube without proper indications is contraindicated.
C) Assessing the client's respiratory status frequently:
Frequent assessment of the client's respiratory status is crucial when managing a patient with a chest tube. The nurse should monitor for signs of respiratory distress, changes in breath sounds, oxygen saturation, and any signs of complications such as pneumothorax or hemothorax. Regular respiratory assessment helps in early detection of issues and provides the data necessary to manage the client's care effectively.
D) Monitoring skin for subcutaneous emphysema:
Monitoring for subcutaneous emphysema is a vital part of nursing care for a client with a chest tube. Subcutaneous emphysema occurs when air escapes from the pleural space into the tissues under the skin, and can be a sign of a pneumothorax or a complication related to the chest tube. It is important to detect this early so appropriate intervention can be made to prevent further complications.
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