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 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
The nurse should first administer the client's cefazolinto the client's IV access
Rationale:
Cefazolin is an antibiotic prescribed to treat the client's suspected infection indicated by the fever and hip surgical wound inflammation. Administering the antibiotic promptly is essential to initiate treatment and address the underlying cause of the fever. The prescription specifies administering cefazolin intravenously, so the nurse should prioritize administering it through the client's IV access. Administering acetaminophen or alprazolam may be appropriate based on the client's symptoms and vital signs, but addressing the infection with antibiotics takes precedence.
Correct Answer is D
Explanation
A. Wearing an underwire bra between feedings can compress the breasts and potentially lead to mastitis. Nursing bras without underwire are recommended.
B. Covering the breasts immediately after feedings can trap moisture and promote bacterial growth, increasing the risk of mastitis.
C. Cold compresses can help relieve discomfort from engorgement, but applying them before feedings may hinder milk flow and emptying of the breasts, which could increase the risk of mastitis.
D. Ensuring the baby fully empties the breasts with each feeding helps prevent engorgement and decreases the risk of mastitis by promoting effective milk removal.
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