A nurse is caring for a client who has a chest tube in the pleural space. The nurse notices continuous bubbling in the water seal chamber of the client's drainage system. Which of the following actions should the nurse take?

Raise the drainage system to the client's chest level.

Clamp the tubing to check for air leaks.

Empty the collection chamber.

Gently squeeze the tubing to remove excess drainage.

Answer and Explanation

The Correct Answer is B

B. The appropriate action for a nurse to take would be to check for air leaks in the system. This can be done by clamping the tubing momentarily to see if the bubbling stops, which would suggest the presence of a leak.

A The drainage system should always be kept below the level of the chest and should not be raised or emptied unless specifically indicated.

C. Emptying the collection chamber is typically unnecessary unless it is nearing full capacity. Continuous bubbling in the water seal chamber does not indicate that the collection chamber needs immediate emptying.

D. Squeezing the tubing can disrupt the functioning of the drainage system and is not recommended. Drainage should flow passively into the collection chamber without external manipulation.

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Correct Answer is C

Explanation

C. This statement highlights difficulty with a specific ADL (grooming) that OT can assess and intervene to improve independence and quality of life.

A Difficulty swallowing, preference for a wheelchair over a walker, and problems with bladder control may also require medical attention, but they are not directly related to the occupational therapy's primary focus on improving the patient's ability to perform daily activities

B. This statement suggests mobility issues and possibly difficulty with walking due to muscle weakness. While mobility aids such as wheelchairs and walkers are typically addressed by physical therapists, OT can also be involved in evaluating the client's preferences, abilities, and functional mobility needs.

D. While OT primarily focuses on ADLs and functional tasks, bladder control problems typically require evaluation and management by a urologist or specialist in urology.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Fluid volume deficit

The client is receiving Furosemide (a diuretic) at a significant dose (80 mg IV three times per day). This medication promotes diuresis to reduce fluid overload in heart failure. The client's weight decreased from 97.5 kg on admission to 90.7 kg on Day 2, indicating a fluid loss of approximately 6.8 kg (about 15 pounds). This substantial weight loss suggests a risk for fluid volume deficit, which can lead to hypovolemia and potential complications such as hypotension and decreased tissue perfusion.

Acute kidney injury (AKI)

The client's BUN level increased from 10 mg/dL on admission to 20 mg/dL on Day 2, which suggests impaired kidney function. This change may indicate a decrease in glomerular filtration rate due to decreased renal perfusion secondary to fluid loss from diuresis. AKI is a known complication in heart failure patients receiving diuretic therapy, especially if there is inadequate monitoring and adjustment of diuretic doses.

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A nurse is caring for a client who has a chest tube in the pleural space. The nurse notices continuous bubbling in the water seal chamber of the client's drainage system. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has myasthenia gravis. Which of the following client statements should indicate to the nurse that the client needs a referral for occupational therapy?

Correct Answer is C

Explanation

A nurse is caring for a client who has heart failure. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing dropdown and dropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

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