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 A

Explanation

A. GI intolerance and neutropenia: Antiretroviral therapy can cause gastrointestinal intolerance, including nausea, vomiting, diarrhea, and abdominal pain. Neutropenia, a decrease in neutrophil count, can also occur as a side effect of some antiretroviral medications.

B. T-cell count of 500 and diarrhea: While diarrhea can be a side effect of antiretroviral therapy, a T-cell count of 500 is not necessarily an adverse effect and may indicate effective treatment.

C. Anorexia and constipation: Anorexia and constipation are not commonly associated with antiretroviral therapy. However, gastrointestinal side effects such as diarrhea are more common.

D. Bone demineralization and thrush: Bone demineralization (osteoporosis) can occur as a long- term complication of HIV infection and antiretroviral therapy, but it is not a direct adverse effect of antiretroviral medications. Thrush (oral candidiasis) can occur in HIV-infected individuals, but it is not specifically related to antiretroviral therapy.

A. Grilled chicken, white rice, sliced peaches. B. Spaghetti with tomato sauce, meatballs, and garlic bread. C. Fried shrimp, cauliflower, yogurt with granola. D. Grilled salmon, brown rice, broccoli.

Correct Answer is D

Explanation

A. Grilled chicken, white rice, sliced peaches: While grilled chicken is a lean protein source, white rice is low in fiber and may not be the best choice for someone experiencing severe diarrhea. Sliced peaches are a good fruit choice, but the meal lacks sufficient fiber and other nutrients.

B. Spaghetti with tomato sauce, meatballs, and garlic bread: This meal contains high-fat and high-carbohydrate foods, which may exacerbate diarrhea. Tomato sauce can be acidic and irritating to the digestive system for some individuals.

C. Fried shrimp, cauliflower, yogurt with granola: Fried foods are high in fat and may worsen diarrhea. Cauliflower is a good vegetable choice, but yogurt with granola may not be well- tolerated if the client is lactose intolerant or sensitive to dairy products.

D. Grilled salmon, brown rice, broccoli: Grilled salmon provides lean protein and omega-3 fatty acids, which can be beneficial for overall health. Brown rice is higher in fiber compared to white rice and can help regulate bowel movements. Broccoli is a good source of fiber and essential nutrients. This meal is well-balanced and nutritious, making it a suitable choice for someone experiencing diarrhea.

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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 A

Explanation

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Correct Answer is D

Explanation

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