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 A
Explanation
Hyperextended position, or backward bending of the neck, is the correct position for the client's neck during a bronchoscopy procedure with a rigid scope and general anesthesia. This position allows the provider to insert the scope through the mouth and into the trachea and bronchi, while avoiding injury to the teeth, tongue, or larynx. It also facilitates visualization of the airways and removal of foreign bodies or secretions.
b) Neutral position, or alignment of the head and neck with the spine, is not the correct position for the client's neck during a bronchoscopy procedure with a rigid scope and general anesthesia. This position may interfere with the insertion of the scope and cause damage to the oral structures or airways.
c) Extended position, or forward bending of the neck, is not the correct position for the client's neck during a bronchoscopy procedure with a rigid scope and general anesthesia. This position may obstruct the airway and make it difficult for the provider to insert the scope and access the bronchi.
d) Flexed position, or downward bending of the neck, is not the correct position for the client's neck during a bronchoscopy procedure with a rigid scope and general anesthesia. This position may compress the airway and prevent adequate ventilation and oxygenation of the client.
Correct Answer is A
Explanation
This statement indicates an understanding of the teaching, as weight loss is one of the most effective ways to decrease the number of nightly apneic episodes in clients who are obese and have obstructive sleep apnea. Obstructive sleep apnea is a condition in which the upper airway collapses or becomes blocked during sleep, causing pauses in breathing and hypoxia. Obesity is a major risk factor for obstructive sleep apnea, as excess fat tissue around the neck and throat can narrow the airway and increase its collapsibility. Losing weight can reduce the pressure on the airway and improve its patency.
b) "I sleep better if I take a sleeping pill at night." This statement indicates a lack of understanding of the teaching, as sleeping pills are not recommended for clients who have obstructive sleep apnea. Sleeping pills can worsen the condition by relaxing the muscles of the throat and tongue, which can further obstruct the airway and decrease the arousal response to hypoxia. The nurse should advise the client to avoid sleeping pills and other sedatives or alcohol before bedtime.
c) "It might help if I tried sleeping only on my back." This statement indicates a lack of understanding of the teaching, as sleeping on the back is not helpful for clients who have obstructive sleep apnea. Sleeping on the back can increase the risk of airway obstruction by allowing gravity to pull the tongue and soft palate backward, which can block the airway and cause snoring and apnea. The nurse should suggest that the client try sleeping on the side or elevate the head of the bed to prevent this.
d) "I should get a humidifier to run at my bedside at night." This statement indicates a lack of understanding of the teaching, as a humidifier is not likely to decrease the number of nightly apneic episodes in clients who have obstructive sleep apnea. A humidifier can moisten the air and ease breathing for clients who have dry or irritated nasal passages, but it does not address the underlying cause of airway obstruction or hypoxia. The nurse should inform the client that a humidifier may not be effective for obstructive sleep apnea and may increase the risk of infection or mold growth if not cleaned properly.
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