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.

Answer and Explanation

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.

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Correct Answer is ["100"]

Explanation

To calculate the infusion rate, use the formula:

mL/hr = (volume of solution in mL / time of infusion in hr) x 60 min/hr

Plug in the given values:

mL/hr = (50 mL / 0.5 hr) x 60 min/hr

Simplify and solve:

mL/hr = 100 x 60 min/hr

mL/hr = 100 mL/hr

Round to the nearest whole number and add a leading zero if needed:

mL/hr = 100 mL/hr

Correct Answer is ["2"]

Explanation

2 capsules

To calculate the number of capsules, use the formula:

capsules = (desired dose in mg / available dose in mg) x 1 capsule

Plug in the given values:

capsules = (300 mg / 150 mg) x 1 capsule

Simplify and solve:

capsules = 2 x 1 capsule

capsules = 2 capsules

Round to the nearest whole number and add a leading zero if needed:

capsules = 2 capsules

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["100"]

Explanation

A nurse is preparing to administer lithium 300 mg PO every 8 hr. Available is lithium carbonate 150 mg capsules. How many capsules should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["2"]

Explanation

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