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. "When the doctor comes to see you, we can talk about whether you will need a transplant." This response acknowledges the client's concerns and opens the door for further discussion with the healthcare provider about the client's prognosis and potential need for a kidney transplant. It provides an opportunity for the client to receive accurate information from the appropriate healthcare professional.

B. "Kidney transplantation is likely, and it would be a good idea to start talking to family members." This response may cause unnecessary anxiety and speculation for the client without

confirmation from the healthcare provider. It is important to provide information based on the client's specific situation and medical assessment.

C. "No, don't think that. You're going to be fine in a few weeks." This response provides false reassurance and does not address the client's concerns or the potential seriousness of acute kidney injury. It is essential to provide honest and accurate information to the client.

D. "Your condition can be reversed with prompt treatment and usually will not destroy the kidney." While acute kidney injury can sometimes be reversible with prompt and appropriate treatment, it is not always the case. Additionally, it does not address the potential need for a kidney transplant, which depends on the severity and underlying cause of the kidney injury.

A. Reports of joint pain. B. Increase in appetite. C. Progressive edema. D. Recent increase in thirst.

Correct Answer is C

Explanation

A. Reports of joint pain: Joint pain is more indicative of musculoskeletal issues rather than chronic renal disease. While joint pain can occur in some types of kidney disease, progressive edema is a more specific symptom.

B. Increase in appetite: An increase in appetite is not typically associated with chronic renal disease. Instead, clients with kidney disease may experience a decrease in appetite due to various factors such as nausea, vomiting, and changes in taste.

C. Progressive edema: Progressive edema, especially in the lower extremities and around the eyes (periorbital edema), can be a significant indicator of declining kidney function. It results from fluid retention due to impaired kidney filtration.

D. Recent increase in thirst: While increased thirst can be a symptom of chronic renal disease, it is not as specific as progressive edema. Increased thirst may occur due to other conditions or factors such as diabetes mellitus or dehydration.

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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 C

Explanation

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