A nurse is caring for a client who has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication?
Continuous bubbling in the water-seal chamber
Occasional bubbling in the water-seal chamber
Fluctuations in the fluid level in the water-seal chamber
Constant bubbling in the suction-control chamber
The Correct Answer is A
Choice A Reason: Continuous bubbling in the water-seal chamber indicates an air leak in the chest tube system, which can compromise the drainage of air and fluid from the pleural space and impair lung expansion.
Choice B Reason: Occasional bubbling in the water-seal chamber is normal and expected, as it indicates that air is being removed from the pleural space.
Choice C Reason: Fluctuations in the fluid level in the water-seal chamber are normal and expected, as they reflect changes in intrathoracic pressure during inspiration and expiration.
Choice D Reason: Constant bubbling in the suction-control chamber is normal and expected, as it indicates that suction is being applied to the chest tube system.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because dextrose 5% in 0.9% sodium chloride is a hypertonic solution that can cause fluid overload and pulmonary edema in a client who has burns.
Choice B Reason: This is incorrect because dextrose 5% in water is a hypotonic solution that can cause fluid shifts from the intravascular space to the interstitial space, resulting in hypovolemia and hypotension in a client who has burns.
Choice C Reason: This is incorrect because 0.9% sodium chloride is an isotonic solution that can cause hypernatremia and hyperchloremia in a client who has burns, as the fluid loss from burns is greater than the sodium loss.
Choice D Reason: This is correct because lactated Ringer's is an isotonic solution that contains electrolytes similar to plasma, such as sodium, potassium, calcium, and chloride. It also contains lactate, which is converted to bicarbonate in the liver and helps correct the metabolic acidosis that occurs in a client who has burns.
Correct Answer is B
Explanation
Choice A Reason: This choice is incorrect because furosemide is a diuretic that helps to reduce fluid retention and edema. It may be used for clients who have heart failure or hypertension, but it does not treat pulmonary embolism.
Choice B Reason: This choice is correct because heparin is an anticoagulant that helps to prevent blood clots from forming or growing larger. It may be used for clients who have pulmonary embolism, which is a blockage of a pulmonary artery by a blood clot that usually originates from a deep vein thrombosis (DVT). Heparin can reduce the risk of complications such as pulmonary infarction or death.
Choice C Reason: This choice is incorrect because dexamethasone is a corticosteroid that helps to reduce inflammation and immune response. It may be used for clients who have allergic reactions, asthma, or autoimmune diseases, but it does not treat pulmonary embolism.
Choice D Reason: This choice is incorrect because epinephrine is a sympathomimetic that helps to stimulate the heart and blood vessels. It may be used for clients who have cardiac arrest, anaphylaxis, or severe asthma, but it does not treat pulmonary embolism.
Choice E Reason: This choice is incorrect because atropine is an anticholinergic that helps to block the effects of acetylcholine on the heart and smooth muscles. It may be used for clients who have bradycardia, atrioventricular block, or organophosphate poisoning, but it does not treat pulmonary embolism.
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