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 A
Explanation
A A change in level of consciousness (LOC), such as confusion, lethargy, or loss of consciousness, can indicate worsening neurological status. It reflects impaired brain function due to increased pressure on brain tissues.
B. Pupillary changes, such as dilation or asymmetry, can occur due to pressure on the oculomotor nerve (cranial nerve III). Pupillary dilation can be a sign of increased ICP but typically occurs after other neurological changes.
C. Decorticate posturing indicates significant neurological impairment but typically appears after alterations in consciousness.
D. Cheyne-Stokes respirations indicate brainstem involvement and impaired respiratory control but are generally seen later in the progression of neurological deterioration.
Correct Answer is A
Explanation
A Pain typically occurs when the stomach is empty (1-3 hours after eating), often during the night and early morning. This pattern occurs because the presence of food helps to buffer gastric acid, whereas an empty stomach allows acid to directly contact the ulcerated area, leading to pain.
B. Pain in the right lower quadrant is not typically associated with peptic ulcer disease. Pain in PUD is usually located in the epigastric region (upper abdomen), although it can radiate to the back or other areas depending on the location and severity of the ulcer.
C. Constipation is not a typical finding in peptic ulcer disease. PUD is primarily associated with gastrointestinal symptoms related to acid-peptic imbalance, such as abdominal pain, bloating, nausea, and sometimes vomiting. Bowel habits are generally not directly affected by PUD.
D. In peptic ulcer disease, pain is usually relieved by eating or taking antacids. This is because food intake neutralizes gastric acid and provides a temporary protective coating over the ulcer, reducing irritation and pain.
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