While caring for a patient with a chest tube, you observe continuous bubbling in the water-seal chamber of the drainage system.

What action should you take?

Increase the suction pressure.

Clamp the chest tube.

Document the finding as normal.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Increasing the suction pressure would not address the underlying issue of an air leak and could potentially worsen the patient's condition by causing further lung collapse or trauma. Continuous bubbling in the water-seal chamber indicates a persistent air leak from the pleural space, tubing, or at the insertion site, which needs to be identified and resolved. Adjusting the suction without finding the source of the leak is an inappropriate intervention.

Choice B rationale

Clamping the chest tube is a dangerous intervention as it can lead to a tension pneumothorax, a life-threatening condition. Clamping prevents air and fluid from exiting the pleural space, causing pressure to build up and compress the lung, heart, and great vessels. This action should only be performed for very brief periods under specific, controlled circumstances, such as when changing the drainage system.

Choice C rationale

Continuous bubbling in the water-seal chamber is not a normal finding. Normal bubbling in this chamber should only occur intermittently with the patient's respirations, indicating the resolution of the pneumothorax. Continuous bubbling signifies an ongoing air leak, which requires investigation. The nurse must not document this as a normal finding but rather as an abnormal assessment that warrants immediate action.

Choice D rationale

Continuous bubbling in the water-seal chamber indicates a persistent air leak in the pleural space or the drainage system. The nurse must systematically check all connections from the insertion site to the drainage unit to identify and correct the source of the leak. The goal is to ensure the integrity of the closed system to prevent atmospheric air from entering the chest and to facilitate lung re-expansion.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["1.5"]

Explanation

The patient has an order for Coumadin 3.75 mg today. The pill from the pharmacy is 2.5 mg. How many pills would you give?.

Step 1: Calculate the number of pills needed. 3.75 mg ÷ 2.5 mg = 1.5 pills. The nurse would give 1.5 pills.

A. Loss of temperature regulation. B. Sensory malfunction. C. Major fluid shift. D. Impaired balance.

Correct Answer is ["A","C"]

Explanation

Choice A rationale

Burns destroy the protective layers of the skin, including the epidermis and dermis, which are essential for maintaining body temperature. This damage leads to a significant loss of heat through evaporation and impaired vasoregulation, making the patient highly susceptible to hypothermia. This is a critical physiological disruption that requires meticulous thermoregulatory support.

Choice B rationale

Sensory malfunction is not a primary concern with full thickness burns. Full thickness burns, also known as third-degree burns, destroy nerve endings in the affected area, leading to a loss of sensation, not a malfunction. The main issues are systemic, such as fluid shifts and loss of thermoregulation, which are more immediately life-threatening.

Choice C rationale

A major fluid shift is a hallmark of severe burns. The immense tissue damage causes increased capillary permeability, leading to a massive leakage of plasma and proteins from the intravascular space into the interstitial space. This results in hypovolemia, edema, and a significant risk of burn shock, which requires aggressive fluid resuscitation to prevent.

Choice D rationale

Impaired balance is not a typical or primary complication of burns. While large burns can affect mobility and cause generalized weakness, balance issues are not a direct physiological consequence of the burn injury itself. The focus of burn care is on managing the more critical and systemic complications, such as hypovolemia, infection, and thermoregulatory dysfunction. *.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

While caring for a patient with a chest tube, you observe continuous bubbling in the water-seal chamber of the drainage system.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The patient has an order for Coumadin 3.75 mg today. The pill from the pharmacy is 2.5 mg. How many pills would you give?

Correct Answer is ["1.5"]

Explanation

A patient has suffered a deep, full thickness burn after a car fire. The nurse understands that burns can cause more than just body tissue damage. Which issues are the main areas of focus when caring for patients with burns? Select all three that apply.

Correct Answer is ["A","C"]

Explanation

The nurse is caring for a patient with pulmonary hypertension. The nurse knows that which manifestation is common with this disorder?

A patient has a rash on her left elbow and a small amount on both knees. The rash is patchy, red, and has thick, silvery scales. What type of rash is this most likely

The patient has an order for heparin 100 units over one hour. Heparin from the pharmacy comes as 10,000 units in 500 ml. The nurse should set the pump to deliver how many ml/hr?

Which assessment information obtained by the nurse when caring for a patient receiving mechanical ventilation indicates a need for suctioning?

The nurse prepares to assist the health care provider with the removal of a patient's chest tube. Which priority instruction should the nurse provide to the patient immediately before removal?

A 22-year-old patient has an itchy rash on his left arm that has been diagnosed as contact dermatitis. Which of the following patient statements indicates a need for more education?

Which of the following substances is most likely to cause skin irritation in an individual with irritant-type contact dermatitis?

A nurse cares for a patient who had a chest tube placed six hours ago and refuses to take deep breaths because of the pain. What action should the nurse take?