A nurse is caring for a client who has a chest tube. The client asks why the fluid in the water-seal chamber rises and falls.
Which of the following statements should the nurse make?
"This indicates a possible air leak.".
"This means your lung is fully re-expanded.".
"Your breathing pattern causes this.".
"Suction pressure that is too high causes this.".
The Correct Answer is C
The fluctuation of fluid in the water-seal chamber of a chest tube is known as tidaling and is caused by the changes in pressure within the chest during respiration.
Choice A is not correct because tidaling does not indicate an air leak.
Choice B is not correct because tidaling does not necessarily mean that the lung is fully re-expanded.
Choice D is not correct because suction pressure does not cause tidaling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should plan to insert a large-bore nasogastric tube for a client who has upper gastrointestinal bleeding due to a peptic ulcer.
This allows for gastric lavage and can help diagnose the source of bleeding.
Choice A is wrong because a 22-gauge IV line may be too small for rapid fluid resuscitation.
Choice B is wrong because ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of gastrointestinal bleeding.
Choice C is wrong because nitroprusside is a vasodilator used to treat hypertensive emergencies and is not typically used for upper gastrointestinal bleeding.
Correct Answer is C
Explanation
“Weight loss of.8 kg (4 Ib) in the past 24 hr.” Furosemide is a diuretic that decreases the pressure caused by excess fluid in the heart and lungs.
A weight loss of.8 kg (4 Ib) in the past 24 hr indicates that excess fluid is being removed from the body, which is a sign that the medication is effective.
Choice A is incorrect because adventitious breath sounds are a symptom of pulmonary edema, not an indication that the medication is effective.
Choice B is incorrect because furosemide has direct vasodilatory outcomes 2, which would decrease blood pressure, not elevate it.
Choice D is incorrect because there is no information found to support this statement.
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