A nurse is assessing a client with a chest tube and observes the water level in the water seal bubbling as the client breathes. How should the nurse best respond to this assessment finding?

Inform the health care provider that there is a probable leak in the drainage system.

Encourage the client to breathe deeply so the water seal will stabilize.

Inform the health care provider that the client is ready to have the chest tube removed.

Document that the chest drainage system is functioning as intended.

Answer and Explanation

The Correct Answer is D

A. Inform the health care provider that there is a probable leak in the drainage system: Bubbling in the water seal chamber of a chest drainage system during client breathing is an expected finding and indicates air movement in and out of the pleural space. It does not necessarily indicate a leak in the drainage system. Documenting the observation and assessing the client for other signs of complications would be appropriate before informing the healthcare provider.

B. Encourage the client to breathe deeply so the water seal will stabilize: Deep breathing by the client will not stabilize the water seal. The bubbling occurs due to air movement in and out of the pleural space during respiration and is a normal finding.

C. Inform the health care provider that the client is ready to have the chest tube removed: Bubbling in the water seal chamber does not necessarily indicate that the client is ready to have the chest tube removed. The decision to remove a chest tube is based on various factors, including the client's clinical status and resolution of the underlying condition requiring chest drainage.

D. Document that the chest drainage system is functioning as intended: Bubbling in the water seal chamber during client breathing indicates that the chest drainage system is functioning as intended. It is an expected finding and does not typically require intervention.

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Correct Answer is B

Explanation

A. This result shows a slightly elevated PaCO2, which could suggest respiratory compensation for a metabolic alkalosis, not acidosis, as the pH is within the normal range.
B. This result indicates both a low pH and an elevated PaCO2, which are consistent with respiratory acidosis. The low HCO3 also suggests a metabolic acidosis component, making it the best match for a client with acidosis.

C. The elevated pH indicates alkalosis. The low PaCO2 and high HCO3 further suggest a primary respiratory alkalosis with metabolic compensation.
D. These values are within normal limits, indicating neither acidosis nor alkalosis.

A. Client has increased urine specific gravity. B. Changes in the client's behavior. C. Client is complaining of nausea. D. Client is complaining of severe headache. E. Client's urine output is only 50 cc/hr.

Correct Answer is ["A","B","C","D"]

Explanation

A. Client has increased urine specific gravity: Increased urine specific gravity indicates concentrated urine, which is a hallmark of SIADH and should be reported as it reflects the excessive retention of water.

B. Changes in the client's behavior: Behavioral changes can be indicative of hyponatremia, a serious complication of SIADH, and should be reported immediately.

C. Client is complaining of nausea: Nausea is a symptom of hyponatremia, which is a common and dangerous consequence of SIADH that needs prompt attention.

D. Client is complaining of severe headache: A severe headache can also be a sign of hyponatremia and potential cerebral edema, both of which are critical conditions needing urgent intervention.

E. Client's urine output is only 50 cc/hr: While reduced urine output can be associated with SIADH, 50 cc/hr is not extremely low and might not be immediately alarming on its own. The other symptoms are more critical and should take precedence in reporting to the provider.

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A nurse is assessing a client with a chest tube and observes the water level in the water seal bubbling as the client breathes. How should the nurse best respond to this assessment finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Explanation

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