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

A To obtain reliable results, it is generally recommended to collect samples from different areas of the stool across multiple bowel movements rather than from a single sample.

detecting occult blood if it is present in the stool but not evenly distributed throughout. It also helps to reduce the chance of obtaining a false negative result.

C. Urine can interfere with the accuracy of fecal occult blood testing, leading to false positive results. Therefore, any sample that contains visible urine should be discarded to prevent inaccurate test results.

B. While gloves should be worn to maintain standard precautions and prevent direct contact with feces, sterile gloves are not required for this procedure. Standard medical examination gloves are sufficient to ensure hygiene and prevent contamination during sample collection.

D. The guaiac smear should be performed on a small portion of stool obtained from different areas within the bowel movement, not specifically from the outer edge of formed stool. The goal is to sample from different parts to increase the likelihood of detecting any occult blood present.

A. Tie knots in the ropes near the pulleys to shorten them. B. Increase the elevation of the affected extremity. C. Remove one of the weights. D. Pull the client up in bed.

Correct Answer is D

Explanation

D. The appropriate action would be to adjust the patient's position to restore the correct alignment and tension of the traction. This typically involves pulling the client up in bed to ensure that the weights hang freely and exert the necessary force for effective traction.

A It is not recommended to tie knots in the ropes as this action could disrupt the prescribed traction force and alignment.

B. It is helpful for other aspects of care but does not correct the traction issue caused by the weights resting on the floor.

C. This is not the correct action because it would decrease rather than increase the traction force, which is necessary for fracture alignment and healing.

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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 preparing to obtain a guaiac smear sample from a client for fecal occult blood testing. Which of the following actions should the nurse plan to take?

Correct Answer is ["C"]

Explanation

A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are resting on the floor. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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