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 A
Explanation
A.
A. Educating the client on covering the nose and mouth with tissues when coughing helps prevent the spread of tuberculosis by containing respiratory secretions.
B. A client with active tuberculosis should not return to work until they have completed a sufficient duration of treatment and are deemed non-infectious, not solely based on negative sputum cultures.
C. The client remains contagious until they have been on appropriate medication therapy for a sufficient duration and are deemed non-infectious by healthcare providers, usually after several weeks of treatment rather than just one week.
D. While wearing protective masks may be recommended for healthcare workers or individuals with compromised immune systems, it's not necessary for the client's family members unless they are in close contact with the client for an extended period.
Correct Answer is B
Explanation
A. "My stoma size will stay the same, even after it has healed." - This statement is incorrect.
Stoma size can change during the healing process and may continue to evolve over time due to factors such as swelling, retraction, or prolapse.
B. "My stoma will drain liquid fluid continuously." - This statement is correct. In an ileostomy, the stoma typically drains liquid stool continuously due to the absence of the colon, which is responsible for absorbing water from the feces.
C. "I will change my pouch system every 2 weeks." - This statement is incorrect. The frequency of pouch changes depends on individual factors such as stoma size, type of pouching system used, and personal preference. It is essential to teach clients to change their pouch when needed, which may vary from a few days to a week or longer.
D. "I will ensure that my medications are enteric coated." - This statement is unrelated to ileostomy care. Enteric-coated medications are designed to resist dissolution in the acidic environment of the stomach and instead dissolve in the alkaline environment of the small intestine. It is not directly relevant to stoma care.
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