A nurse is caring for a client who has a three-chamber 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?
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
Continuing to monitor the client is the appropriate action for the nurse to take, as a rise in the water seal chamber with client inspiration is a normal and expected finding. The water seal chamber acts as a one-way valve that allows air to exit from the pleural space and prevents air from entering. The water level in this chamber fluctuates with breathing, rising with inspiration and falling with expiration. This indicates that the chest tube system is functioning properly and that there is no air leak.
a) Immediately notifying the provider is not necessary, as a rise in the water seal chamber with client inspiration is not an abnormal or urgent finding. The nurse should only notify the provider if there are signs of complications, such as persistent bubbling in the water seal chamber, which indicates an air leak, or no fluctuation in the water level, which indicates an obstruction or resolution of pneumothorax.
b) Clamping the chest tube near the water seal is not advisable, as it can cause increased pressure in the pleural space and lead to tension pneumothorax. Clamping the chest tube should only be done for a brief period of time and under specific circumstances, such as changing the drainage system, assessing for an air leak, or preparing for chest tube removal.
d) Repositioning the client toward the left side is not helpful, as it does not affect the water level in the water seal chamber. The nurse should position the client according to their comfort and condition, and avoid placing them flat or on their affected side, as this can impair drainage and ventilation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
These actions help to control bleeding, reduce blood pressure, and promote clotting.
a. Tilt the client's head backward. This is not recommended, as it can cause blood to drain into the throat and increase the risk of aspiration, nausea, or vomiting.
d. Instruct the client to blow his nose. This is not advisable, as it can dislodge any clots that have formed and worsen bleeding.
Correct Answer is D
Explanation
Smoking cessation is the most effective way to prevent chronic bronchitis, which is a type of chronic obstructive pulmonary disease (COPD) characterized by inflammation and excess mucus production in the
bronchi. Smoking is the main cause of chronic bronchitis, as it damages the cilia and mucous membranes of the airways, leading to chronic cough, sputum, and infection. Quitting smoking can reduce the risk of developing or worsening chronic bronchitis and improve lung function and quality of life.
a) Regular moderate exercise is beneficial for preventing chronic bronchitis, but not as effective as smoking cessation. Exercise can improve cardiovascular and respiratory health, increase oxygen delivery to the tissues, and enhance immune function. However, exercise alone cannot reverse the damage caused by smoking or prevent further deterioration of the airways.
b) Maintenance of ideal weight is beneficial for preventing chronic bronchitis, but not as effective as smoking cessation. Maintaining a healthy weight can reduce the workload on the heart and lungs, prevent obesity-related complications, and improve self-esteem and well-being. However, weight management alone cannot restore the normal structure and function of the airways or prevent chronic inflammation and mucus production.
c) Annual influenza immunization is beneficial for preventing chronic bronchitis, but not as effective as smoking cessation. Influenza immunization can protect against viral infections that can trigger or exacerbate chronic bronchitis symptoms, such as fever, cough, wheezes, and dyspnea. However, influenza immunization cannot prevent other causes of chronic bronchitis, such as bacterial infections, environmental pollutants, or genetic factors.
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