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 B
Explanation
B. Slowing the infusion rate of 0.9% sodium chloride and contacting the provider are appropriate initial actions to manage the client's dyspnea and hypertension, which are likely due to fluid overload from the IV infusion.
A Corticosteroids are not typically indicated for dyspnea and hypertension related to IV fluid administration with 0.9% sodium chloride.
C Changing the type of IV fluid to lactated Ringer's solution may be considered in some cases to address fluid balance issues. However, this decision should be made in consultation with the healthcare provider based on the client's specific clinical condition and fluid status.
D. Lowering the head of the bed to semi-Fowler's position can help improve respiratory function and reduce dyspnea. However, this action alone does not address the underlying cause of the client's symptoms.
Correct Answer is A
Explanation
A Nitroglycerin is a vasodilator that helps relieve angina by dilating blood vessels and increasing blood flow to the heart muscle. It is typically the first-line medication for acute angina attacks. Administering nitroglycerin promptly can help alleviate the client's pain and prevent progression to a myocardial infarction (heart attack).
B. Aspirin is often administered to clients with suspected myocardial ischemia or infarction because it inhibits platelet aggregation, which can reduce the risk of clot formation and further occlusion of coronary arteries. It is typically given early in the management of acute coronary syndrome to prevent clotting complications.
C. While monitoring blood pressure is important in clients with acute angina, especially to assess for hypotension which could indicate cardiogenic shock, it is not the first action. Immediate pain relief and prevention of further ischemic damage take precedence over blood pressure measurement.
D. IV access is important for administering medications and fluids if needed, but it is not the first priority unless the client's condition warrants immediate IV medication administration (such as in severe pain or impending myocardial infarction).
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