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 B
Explanation
Choice A rationale:
Absence seizures typically last for a few seconds, not 30 to 60 seconds. This choice is incorrect because it provides inaccurate information about the duration of absence seizures.
Choice B rationale:
Absence seizures are brief episodes of staring that can be mistaken for daydreaming. It is crucial for the parent to recognize this symptom to ensure the child's safety and seek appropriate medical attention if needed.
Choice C rationale:
Absence seizures usually occur without warning or an aura. There is no specific warning sign before the onset of absence seizures, making this choice incorrect.
Choice D rationale:
Absence seizures have a sudden onset and offset without any warning signs, so they do not have a gradual onset. This information is incorrect regarding absence seizures.
Correct Answer is D
Explanation
Choice A rationale:
Taking antibiotics when having a virus is not a correct understanding of infection prevention. Antibiotics are ineffective against viruses and should only be used for bacterial infections under the guidance of a healthcare provider. This statement indicates a misunderstanding of infection prevention.
Choice B rationale:
Washing hands for at least 20 seconds with soap and water is the recommended practice for infection prevention. Washing hands for 10 seconds may not be sufficient to remove all germs effectively. This statement does not demonstrate a proper understanding of hand hygiene.
Choice C rationale:
Cleaning a cat's litter box during pregnancy is not recommended due to the risk of contracting toxoplasmosis, a parasitic infection that can harm the fetus. Pregnant individuals should avoid handling cat litter to prevent exposure to this infection. This statement indicates a lack of awareness regarding infection prevention during pregnancy.
Choice D rationale:
Waiting 5 days after the chickenpox sores have crusted before visiting a person with chickenpox demonstrates an understanding of infection prevention. Chickenpox is highly contagious, and individuals should avoid close contact until the sores have fully healed and crusted over. This statement reflects appropriate knowledge about preventing the spread of contagious diseases during pregnancy.
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