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","D","E"]
Explanation
A A perforated eardrum can lead to conductive hearing loss, where sound waves cannot efficiently travel through the middle ear to the inner ear.
D. Chronic infections of the middle ear (otitis media) can cause damage to the delicate structures of the middle ear, including the ossicles (bones) and the eardrum, leading to conductive hearing loss or, if severe and untreated, sensorineural hearing loss.
E. Loop diuretics such as furosemide can sometimes cause ototoxicity, which means they can damage the inner ear and lead to hearing loss. This is an important consideration for individuals who are prescribed loop diuretics for medical conditions.
B. High birth weight is not typically considered a significant risk factor for hearing loss unless it was associated with other complications that affected the ears during infancy or childhood.
C. Frequent exposure to low-volume noise is not typically associated with an increased risk of hearing loss
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
The nurse should administer a total 1320ml sodium chloride in the first hour, 880ml each subsequent hour.
Rationale
First Hour Administration
Rate: 15 ml/kg/hr Client's weight: 88 kg
Calculation: 15 ml/kg/hr × 88 kg= 1320ml/hr
Therefore, in the first hour, the nurse should administer 1320 mL of 0.9% sodium chloride.
Subsequent Hour Administration
Rate: 10 ml/kg/hr Client's weight: 88 kg
Calculation: 10 ml/kg/hr × 88kg= 880mls
Therefore, each subsequent hour after the first, the nurse should administer 880 mL of 0.9% sodium chloride.
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