A nurse is caring for a client who has a closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration? Utilize image to see area that is being described.
Immediately notify the provider
Clamp the chest tube near the water seal
Continue to monitor the client
Reposition the client toward the left side
The Correct Answer is C
A. Immediately notify the provider . A rise in the water seal chamber with inspiration (tidaling) is a normal finding, indicating proper function of the chest drainage system. There is no need for immediate provider notification.
B. Clamp the chest tube near the water seal . Clamping the chest tube can lead to a tension pneumothorax by trapping air inside the pleural space. This action is only done temporarily for specific indications, such as assessing for an air leak or changing the drainage system.
C. Continue to monitor the client . Tidaling (fluctuation of water with inspiration and expiration) is expected in the water seal chamber. The nurse should continue to monitor for any sudden cessation of tidaling (which may indicate obstruction) or continuous bubbling (which may indicate an air leak).
D. Reposition the client toward the left side . Position changes do not affect normal tidaling in a functioning chest tube system. However, frequent repositioning is encouraged to promote lung expansion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Checking blood pressure is important but does not confirm a myocardial infarction. Hypotension or hypertension may be present, but they are not definitive diagnostic tools.
B. Auscultating heart tones can help assess for murmurs or extra sounds, but it cannot diagnose a myocardial infarction.
C. Radiating pain to the left arm is a classic symptom, but not all clients experience it, and its absence does not rule out an MI.
D. Performing a 12-lead ECG is the most important diagnostic tool for identifying myocardial infarction. It provides real-time evidence of ischemic changes, such as ST-segment elevation or depression, confirming or ruling out an MI.
Correct Answer is C
Explanation
A. A pulmonary function test is used to assess lung diseases like COPD or asthma. It is not the primary diagnostic test for fluid overload and heart failure.
B. Alpha-1 antitrypsin deficiency is associated with early-onset COPD, but it does not relate to symptoms of fluid retention and heart failure as described in the question.
C. Brain Natriuretic Peptide (BNP) is correct. BNP is released when the ventricles stretch due to fluid overload, making it a key diagnostic marker for heart failure. Elevated BNP levels indicate increased cardiac filling pressures and volume overload, which match the client’s symptoms.
D. A Doppler ultrasound is useful for detecting deep vein thrombosis (DVT) or vascular issues, but it does not assess systemic fluid retention and heart failure.
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