A client had a right-sided chest tube inserted two hours ago for pneumothorax. Which action should the nurse implement if there is no fluctuation in the water seal compartment?
Check the chest tube for kinks or obstructions.
Notify the healthcare provider immediately.
Increase the suction pressure on the chest tube.
Continue to monitor the client and reassess in 1 hour.
The Correct Answer is A
A. If there is no fluctuation in the water seal compartment, the first action should be to check for kinks, obstructions, or other issues in the tubing that might block air or fluid movement. Fluctuation (tidaling) is expected during respiration, and its absence may indicate a problem with the system or that the lung has fully re-expanded.
B. Notifying the healthcare provider immediately is not the first step. The nurse should first assess the chest tube system to determine if there is an issue that can be resolved without medical intervention.
C. Increasing the suction pressure on the chest tube is not appropriate without first identifying the cause of the lack of fluctuation. Adjusting suction may not address the underlying problem.
D. Continuing to monitor and reassess in 1 hour delays addressing the potential issue. Immediate assessment of the chest tube system is necessary to ensure proper functioning.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Letting the client rest alone is not an appropriate intervention for an asthma attack. The client needs reassurance and support during an asthma exacerbation, and isolation can increase anxiety and worsen symptoms.
B. Reassuring the client that the doctor will arrive soon may provide some comfort, but it does not directly address the acute symptoms of dyspnea and anxiety. Immediate interventions to manage the asthma attack should be prioritized.
C. Placing the client on a cardiac monitor and observing from the nurse's station may be appropriate for monitoring heart rate and rhythm, but it does not address the primary concern of managing the asthma attack or anxiety. The nurse should be present to provide direct support and interventions.
D. Staying with the client and encouraging pursed-lip breathing is an effective intervention for managing anxiety and dyspnea during an asthma attack. Pursed-lip breathing helps the client slow their breathing, improve ventilation, and reduce anxiety, which can alleviate dyspnea.
Correct Answer is C
Explanation
A. Buck's extension traction is not used to reduce fractures but to provide comfort, maintain alignment, and reduce muscle spasms in the affected area. Reduction of the fracture typically occurs through surgical intervention.
B. Buck's extension traction is not used to maintain the alignment of pins, as there are no pins involved in this type of traction. It is designed to relieve muscle spasms and provide comfort to the affected limb.
C. Buck's extension traction is primarily used to relieve muscle spasms and provide a steady pull on the affected limb to maintain alignment and reduce pain. This is particularly important in hip fractures to prevent further injury and discomfort.
D. Buck's extension traction does not allow for supported movement of the extremity; instead, it helps to immobilize the limb and reduce muscle spasms.
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