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.

Answer and Explanation

The Correct Answer is B

A. An air leak noted at the insertion site would result in continuous bubbling in the water seal chamber, not the absence of tidaling.

B. If the tubing is kinked or obstructed, it can prevent the movement of air in and out of the water seal chamber, leading to the absence of tidaling.

C. If water needs to be added to the suction-control chamber, this would affect the level of suction, not the tidaling in the water seal chamber.

D. If the suction is set too low, it would not necessarily affect the tidaling in the water seal chamber; instead, it would result in inadequate drainage or lack of suction.

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Correct Answer is B

Explanation

A. Using the injection port farthest from the IV catheter insertion site is not necessary for administering an IV bolus of medication and may not be practical depending on the setup of the IV tubing.

B. Occluding the IV tubing above the injection port prevents the bolus medication from flowing into the continuous IV infusion, ensuring that the medication is delivered directly to the patient.

C. Checking for blood return after medication administration is not relevant in this context, as albumin 5% is administered intravenously and does not require blood return.

D. Flushing the IV tubing with a heparinized solution is not necessary for administering an IV bolus of medication and may not be appropriate for all medications.

A. Blood pressure 94/68 mm Hg B. Urinary output 30 mL/hr C. Respiratory rate 24/min D. Heart rate 152/min

Correct Answer is D

Explanation

A. A blood pressure of 94/68 mm Hg is within the normal range for a 7-year-old child and may indicate compensated dehydration rather than severe dehydration.

B. A urinary output of 30 mL/hr is insufficient and may indicate dehydration, but it does not specifically indicate severe dehydration.

C. A respiratory rate of 24/min is within the normal range for a 7-year-old child and is not specifically indicative of severe dehydration.

D. Tachycardia (heart rate >100 beats per minute) is a common finding in severe dehydration as the body attempts to compensate for decreased blood volume by increasing heart rate.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer an IV bolus of albumin 5% to a client who is receiving a continuous IV infusion. After confirming compatibility, which of the following actions shouldthe nurse take?

Correct Answer is B

Explanation

A nurse is caring for a 7-year-old child who has severe dehydration. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

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