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.
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D. Use a solution of 0.9% sodium chloride to flush the transfusion tubing.
Choice A reason: Storing a unit of blood at room temperature for 1 hour prior to the infusion is not recommended. Blood products should be kept refrigerated until just before the transfusion to minimize the risk of bacterial contamination. The recommended storage temperature for packed RBCs is 1-6°C. If blood is left at room temperature, it should be infused within 30 minutes to ensure safety.
Choice B reason: Ensuring that the transfusion is completed within 6 hours is not correct. The standard practice is to complete a blood transfusion over 2 to 4 hours, depending on the volume and the patient’s condition. This is to reduce the risk of bacterial growth and transfusion reactions. Prolonging the transfusion time beyond 4 hours increases the risk of bacterial contamination and can compromise the efficacy of the transfused red blood cells.
Choice C reason: Obtaining venous access using a 22-gauge needle is not ideal for a transfusion of packed RBCs. A larger bore needle, typically an 18-gauge or 20-gauge, is preferred to ensure adequate flow of the viscous packed RBCs and to prevent hemolysis. The smaller the gauge number, the larger the needle diameter, so a 22-gauge needle might be too small and could damage the red blood cells during the transfusion.
Choice D reason: Using a solution of 0.9% sodium chloride to flush the transfusion tubing is the correct action. Normal saline is isotonic and is the only fluid compatible with packed RBCs. It is used to prime the transfusion set and to flush the line before and after the transfusion to prevent hemolysis and clotting within the tubing.
Correct Answer is A
Explanation
Choice A rationale:
Lavender oil is commonly used in aromatherapy and is known for its calming effects. However, it can trigger respiratory issues in individuals with asthma. Asthma is a chronic condition characterized by airway inflammation and bronchoconstriction, which can be exacerbated by inhaling certain substances, including strong odors and essential oils. Lavender oil, when inhaled, can potentially irritate the airways and worsen asthma symptoms. Therefore, a history of asthma is a contraindication for using lavender oil.
Choice B rationale:
Furosemide is a diuretic commonly used to treat fluid retention (edema) and hypertension. It works by increasing urine production and removing excess fluid from the body. Furosemide does not interact with lavender oil directly, and there is no known contraindication between these two substances.
Choice C rationale:
Alcohol use disorder is a condition characterized by an inability to control or stop alcohol consumption despite negative consequences. While alcohol abuse can have various health implications, it does not specifically interact with lavender oil in a way that constitutes a contraindication.
Choice D rationale:
Vitamin C is a water-soluble vitamin that plays a crucial role in various bodily functions, including immune system support and collagen synthesis. There is no evidence to suggest that taking vitamin C daily contraindicates the use of lavender oil. These two substances do not interact in a way that poses a risk to the individual.
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