A nurse is assessing a client who has a chest tube with a water seal drainage system.
Upon assessment, the nurse notes tidaling in the water seal.
Which of the following is an explanation for the tidaling?

The lung has re-expanded.

There is a loop of tubing below the drainage system.

The system is working properly.

The tubing is partially obstructed by clots.

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C, the system is working properly.

Choice A rationale: The lung has re-expanded is incorrect. If the lung has re-expanded, there would be no tidaling in the water seal chamber, as the pleural space would be restored to its normal negative pressure. Tidaling indicates that there is still air or fluid in the pleural space that needs to be drained

Choice B rationale: There is a loop of tubing below the drainage system is incorrect. A loop of tubing below the drainage system would not cause tidaling in the water seal chamber, but it could cause fluid accumulation in the tubing, which could impair the drainage and increase the risk of infection. The tubing should be straight and free of kinks or loops

Choice C rationale: The system is working properly is correct. Tidaling in the water seal chamber means that the water level rises and falls with the patient’s respirations. This is normal and expected, as it indicates that the chest tube is patent and connected to the pleural space, and that the drainage system is airtight and preventing air or fluid from entering the pleural space. Tidaling should stop when the lung is fully re-expanded or the chest tube is clamped

Choice D rationale: The tubing is partially obstructed by clots is incorrect. If the tubing is partially obstructed by clots, there would be no tidaling in the water seal chamber, as the chest tube would not be able to drain the air or fluid from the pleural space. The water level in the water seal chamber would be stagnant, and the patient may experience respiratory distress. The tubing should be checked regularly for clots and milked gently if needed

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Correct Answer is B

Explanation

Choice A rationale:

Choosing an agency to provide home physical therapy is important, but it is not the priority in this situation. The client's safety and immediate needs should be addressed first.

Choice B rationale:

Obtaining an alert system to get help in case of a fall is the priority for an older adult living alone with left-sided weakness following a stroke. Falls can result in serious injuries, so having an alert system ensures the client can call for assistance promptly, enhancing their safety and well-being.

Choice C rationale:

Providing information about available transportation resources is important for the client's long-term independence and quality of life. However, immediate safety concerns, such as the risk of falls, should be addressed first.

Choice D rationale:

Reviewing information about support groups for individuals who have had a stroke is essential for the client's emotional well-being and social support. However, immediate safety measures, such as fall prevention, take precedence in this scenario.

A. The anterior fontanel is open. B. The posterior fontanel is open. C. Both fontanels show molding. D. Both fontanels are the same size.

Correct Answer is A

Explanation

Choice A rationale:

The anterior fontanel is open in an 8-month-old infant. The anterior fontanel, located at the top of the baby's head where the skull bones have not yet fused, typically closes between 12 to 18 months of age. It is a normal finding in an 8-month-old infant.

Choice B rationale:

The posterior fontanel closes earlier than the anterior fontanel, usually within the first few months of life. It is a smaller diamond-shaped area located at the back of the baby's head. It is not expected to be open in an 8-month-old infant.

Choice C rationale:

Molding refers to the shaping of the fetal head during passage through the birth canal. It can cause temporary changes in the shape of the baby's skull. By 8 months of age, molding is not an expected finding as the skull bones have had time to return to their normal shape.

Choice D rationale:

Both fontanels being the same size is not a typical finding. The anterior fontanel is larger than the posterior fontanel, and their sizes are proportional. Any significant deviation from this proportion could indicate abnormal skull development and should be further assessed.

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A nurse is assessing a client who has a chest tube with a water seal drainage system. Upon assessment, the nurse notes tidaling in the water seal. Which of the following is an explanation for the tidaling?

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Correct Answer is B

Explanation

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Correct Answer is A

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A nurse is assessing a client who has a chest tube with a water seal drainage system.
Upon assessment, the nurse notes tidaling in the water seal.
Which of the following is an explanation for the tidaling?