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 A
Explanation
A. Weight loss is not a common side effect of prednisone. Instead, weight gain due to fluid retention and increased appetite is a frequent side effect.
B. Dry mouth can occur with prednisone use, though it is not the most common side effect.
C. Hyperglycemia is a well-known side effect because corticosteroids increase glucose production and reduce insulin sensitivity.
D. Decreased wound healing is a common effect due to prednisone's immunosuppressive and anti-inflammatory properties, which impair tissue repair.
Correct Answer is A
Explanation
A. "Try taking a mild analgesic to relieve the headache." is correct. Nitroglycerin-induced headaches are a common side effect due to vasodilation. Mild analgesics such as acetaminophen can help alleviate the discomfort.
B. Taking only one dose to reduce the risk of a headache is inappropriate. The client should follow the prescribed dosing regimen to manage angina effectively. Skipping doses may increase the risk of angina attacks.
C. Requesting a different medication is not necessary. Nitroglycerin is an effective treatment for stable angina, and headaches typically diminish over time as the body adjusts to the medication.
D. Stating that nothing can be done to relieve the headaches is incorrect. Headaches from nitroglycerin can be managed with mild analgesics or by adjusting the timing of medication administration.
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