A nurse in the recovery room is assessing a client who has a new chest tube. The nurse finds that the water seal is no longer tidaling. The nurse should identify the finding as resulting from which of the following?
An air leak noted at the insertion site.
The tubing may be kinked.
Water needs to be added to the suction-control chamber.
The suction is set too low.
The Correct Answer is B
A. An air leak noted at the insertion site: An air leak can cause continuous bubbling in the water seal chamber, but it does not prevent tidaling. Tidaling reflects intrathoracic pressure changes with respiration, so an air leak alone does not explain the absence of tidaling.
B. The tubing may be kinked: Tidaling stops when there is an obstruction in the chest tube system, such as a kinked or clamped tube. This prevents the normal movement of fluid in the water seal chamber that corresponds with the client’s respiratory cycle, making it the most likely cause of absent tidaling.
C. Water needs to be added to the suction-control chamber: Low water in the suction-control chamber affects the amount of suction delivered, not tidaling in the water seal chamber. The water seal chamber relies on the client’s respiration to show fluctuations, so adding water to suction does not restore tidaling.
D. The suction is set too low: Suction settings influence the rate of fluid evacuation and bubbling, but they do not control tidaling. Absence of tidaling usually indicates a mechanical obstruction rather than a suction problem.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Cheddar cheese: Cheddar and other aged cheeses contain high levels of tyramine, which can precipitate a hypertensive crisis when consumed by clients taking MAOIs like phenelzine. Avoiding aged cheeses is critical to prevent severe cardiovascular complications.
B. Bananas: Fresh bananas contain low levels of tyramine and are generally safe to consume in moderation while taking MAOIs. Only overripe bananas with high tyramine content should be limited, but this is less of a concern than aged cheeses.
C. Chicken: Fresh chicken does not contain significant tyramine and is safe to include in the diet while taking phenelzine. Properly cooked and stored poultry does not pose a risk for hypertensive crisis.
D. Peanut butter: Peanut butter contains minimal tyramine and is considered safe for clients on MAOIs. Only improperly stored or aged peanut products might pose a slight risk, making it much less critical than avoiding aged cheeses.
Correct Answer is B
Explanation
A. Constipation: Constipation is uncomfortable but usually not life-threatening. It can be addressed after more urgent or potentially serious issues are assessed.
B. Indigestion: Indigestion, especially in a client on a cardiac unit, may indicate angina or myocardial ischemia. Chest discomfort requires immediate assessment to prevent progression to a myocardial infarction, making it the highest priority.
C. Swollen ankles: Peripheral edema can indicate fluid retention or heart failure but is typically a chronic or slowly developing issue. While important to monitor, it is not immediately life-threatening.
D. Urinary frequency: Urinary frequency is generally a non-urgent concern unless associated with other symptoms like pain or signs of infection. It is a lower priority compared to potential cardiac issues.
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