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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A Reason: This choice is incorrect because it indicates respiratory alkalosis, not AKI. Respiratory alkalosis is a condition in which the lungs eliminate too much carbon dioxide (CO2) from the blood, resulting in a low level of CO2 (PaCO2) and a high level of pH. A normal PaCO2 range is 35 to 45 mm Hg, and a normal pH range is 7.35 to 7.45, so a value of 30 mm Hg and 7.49 indicate respiratory alkalosis.

Choice B Reason: This choice is incorrect because it indicates respiratory acidosis, not AKI. Respiratory acidosis is a condition in which the lungs cannot eliminate enough CO2 from the blood, resulting in a high level of CO2 (PaCO2) and a low level of pH. A value of 46 mm Hg and 7.26 indicate respiratory acidosis.

Choice C Reason: This choice is correct because it indicates metabolic acidosis, which is a common complication of AKI. Metabolic acidosis is a condition in which the body produces too much acid or loses too much base, resulting in a low level of bicarbonate (HCO3) and a low level of pH. A normal HCO3 range is 22 to 26 mEq/L, so a value of 14 mEq/L indicates metabolic acidosis. The low PaCO2 value (30 mm Hg) is due to the respiratory compensation mechanism that tries to restore the acid-base balance by increasing the ventilation and eliminating more CO2.

Choice D Reason: This choice is incorrect because it indicates metabolic alkalosis, not AKI. Metabolic alkalosis is a condition in which the body loses too much acid or gains too much base, resulting in a high level of bicarbonate (HCO3) and a high level of pH. A value of 30 mEq/L and 7.49 indicate metabolic alkalosis.

A. Use log rolling to reposition the client. B. Place a warming blanket on the client. C. Instruct the client to cough and deep breathe. D. Place the client in a supine position.

Correct Answer is A

Explanation

Choice A Reason: This is correct because using log rolling to reposition the client helps maintain the alignment of the head and neck, which prevents further increases in ICP.

Choice B Reason: This is incorrect because placing a warming blanket on the client can cause vasodilation and increase cerebral blood ﬂow, which can raise ICP.

Choice C Reason: This is incorrect because instructing the client to cough and deep breathe can increase intrathoracic pressure and impede venous return, which can elevate ICP.

Choice D Reason: This is incorrect because placing the client in a supine position can decrease cerebral perfusion pressure and increase ICP. The client should be placed in a semi-Fowler's position with the head elevated at 30 degrees.

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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?

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