A nurse caring for a patient with a water seal type chest drainage that is on low suction assesses that there is constant bubbling in the suction container. The nurse should:

clamp the chest tube and place the patient in high Fowler's position

immediately turn the patient to the side of the insertion site

document findings

check for air leaks in drainage system

Answer and Explanation

The Correct Answer is D

A. Clamp the chest tube and place the patient in high Fowler’s position: Clamping the tube may cause tension pneumothorax and should be done only with a specific prescription.
B. Immediately turn the patient to the side of the insertion site: This action does not address the source of constant bubbling.
C. Document findings: Bubbling in the suction chamber can be normal, but documenting without further assessment may overlook potential system issues.
D. Check for air leaks in the drainage system: Constant bubbling may indicate an air leak, which requires immediate assessment and correction.

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Correct Answer is C

Explanation

A) Toe. Thickened toenails and edema make this site unreliable for accurate readings.
B) Skin fold. Skin folds are not recommended for pulse oximetry measurements due to poor contact and inconsistent readings.
C) Earlobe. The earlobe is a preferred site in cases of peripheral edema or thickened nails because it has good perfusion and provides reliable readings.
D) Finger. Edema in the hands compromises the accuracy of finger pulse oximetry measurements.

A. "Repeat your breathing exercise every 2 hrs." B. "Inhale through your mouth." C. "Hold your breath for 5 seconds." D. "Exhale through your nose."

Correct Answer is C

Explanation

A) "Repeat your breathing exercise every 2 hrs." Repeating breathing exercises should be done a couple of times every hour to help prevent postoperative complications such as atelectasis and pneumonia.
B) "Inhale through your mouth." Clients should inhale through their nose to filter, warm, and humidify the air.
C) "Hold your breath for 5 seconds." Holding the breath for 5 seconds allows for better lung expansion and optimal oxygen exchange.
D) "Exhale through your nose." Clients are generally advised to exhale through pursed lips to create positive airway pressure and prevent airway collapse.

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A nurse caring for a patient with a water seal type chest drainage that is on low suction assesses that there is constant bubbling in the suction container. The nurse should:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to measure a client's oxygen saturation and notes edema of the client's hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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