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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Antithrombotic medications help to prevent the formation of new clots and keep existing clots from getting larger, which is crucial in the management of patients who have had an ischemic stroke.
A Opioid analgesics are used to relieve pain, typically moderate to severe pain. However, they are not routinely indicated as part of discharge therapy for clients who have had an ischemic stroke
B. Anticonvulsants are medications used to prevent or control seizures. They are not typically used as standard discharge medications for ischemic stroke
C. Diuretics are medications that promote diuresis (increased urine production) and are commonly used to manage conditions such as hypertension and congestive heart failure. They are not typically used as standard discharge medications for ischemic stroke
Correct Answer is A
Explanation
A This response addresses a potential cause of exercise-induced hypoglycemia. Clients with type 1 diabetes often need to adjust their insulin dose or carbohydrate intake before exercise to prevent hypoglycemia. Asking about insulin adjustment is relevant to assess whether the client took appropriate precautions.
B. While exercise can cause fatigue, feeling diaphoretic, having palpitations, and extreme exhaustion are not normal responses after exercise, especially for someone with type 1 diabetes. This response does not address the potential cause of the symptoms.
C. This response addresses the importance of carbohydrate intake post-exercise to prevent or treat hypoglycemia. It encourages the client to reflect on their dietary choices following exercise, which can impact blood glucose levels.
D. While establishing a routine for exercise is beneficial for managing diabetes, this response does not address the immediate concern of hypoglycemia or provide guidance on managing the client's current symptoms.
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