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 A
Explanation
“The client’s capillary refill in the left toe is 6 seconds.” Capillary refill time is the time it takes for blood to return to the capillaries after pressure has been applied to the skin.
A normal capillary refill time is less than 2 seconds.
A capillary refill time of 6 seconds indicates poor blood flow to the left toe and requires immediate intervention by the nurse.
Choice B is not the correct answer because while a pain level of 7 on a scale from 0 to 10 at the operative site is concerning, it does not require immediate intervention by the nurse.
Choice C is not the correct answer because an oral temperature of 38.3° C (100.9° F) is only slightly elevated and does not require immediate intervention by the nurse.
Choice D is not the correct answer because while 100 mL of blood in a closed-suction drain may be concerning, it does not necessarily require immediate intervention by the nurse.
Correct Answer is C
Explanation
The nurse’s priority for immediate intervention is tachypnea, which is rapid breathing.
Tachypnea can be a sign of respiratory distress and requires immediate intervention.
Choice A is wrong because while a fever may indicate an infection, it is not the priority for immediate intervention.
Choice B is wrong because while blood-tinged secretions may indicate bleeding, it is not the priority for immediate intervention.
Choice D is wrong because while IV infiltration may cause discomfort and require attention, it is not the priority for immediate intervention.
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