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 A

Explanation

A Pertussis is highly contagious and spread through respiratory droplets. Wearing a surgical mask when providing care to the client helps prevent the spread of the bacteria to others in the healthcare setting. This is a standard precaution to minimize transmission of respiratory infections.

B. A Mantoux test, or tuberculin skin test, is used to detect tuberculosis (TB) infection, not pertussis. It is not relevant to the diagnosis or management of pertussis. The focus should be on clinical assessment and appropriate treatment for pertussis.

C Pertussis does not typically require isolation in a negative pressure airflow room. Standard precautions, including wearing a surgical mask, are generally sufficient to prevent transmission. Negative pressure rooms are typically reserved for airborne infections like tuberculosis or measles.

D. Pertussis is caused by a bacterial infection (Bordetella pertussis), not a virus. Antiviral therapy is not effective against bacterial infections such as pertussis. Family members and close contacts of the client should receive prophylactic antibiotics to prevent spread of the infection, not antiviral therapy.

A. "Do you feel any burning sensations in your throat?" B. "Do you feel life you have food stuck at the base of your throat?" C. "Do you have any feelings of fullness in the neck?" D. "Do you have any problems with pain while swallowing?"

Correct Answer is B

Explanation

B. Asking the client if they feel like they have food stuck at the base of their throat directly assesses for the hallmark symptom of dysphagia associated with achalasia. This symptom is crucial in diagnosing and monitoring the condition.

A This question assesses for symptoms of esophageal reflux (heartburn), which may not directly relate to the mechanical difficulty of swallowing associated with oral achalasia.

C. This question focuses on sensations of fullness in the neck, which may not specifically relate to swallowing difficulty associated with achalasia.

D. This question assesses for pain during swallowing, which can occur in conditions affecting the throat or esophagus, but it does not specifically address the unique symptom of feeling like food is stuck, which is more typical in achalasia.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse working in the emergency department is admitting a client who has pertussis. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who has oral achalasia. The nurse should ask the client which of the following questions to assess their ability to swallow?

Correct Answer is B

Explanation

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