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 B

Explanation

A humidifier bottle adds moisture to the oxygen, which prevents drying and irritation of the nasal mucosa

and enhances gas exchange.

a. Remove the nasal cannula while the client eats. This is not advisable, as the client may become hypoxic during eating, especially if they have pneumonia and impaired lung function. The nurse should monitor the client's oxygen saturation and respiratory status during meals and adjust the oxygen delivery device as needed.

c. Secure the oxygen tubing to the bed sheet near the client's head. This is not safe, as it can cause entanglement, dislodgement, or kinking of the tubing, which can compromise oxygen delivery and cause injury to the client.

d. Apply petroleum jelly to the nares as needed to soothe mucous membranes. This is not recommended, as petroleum products can ignite in the presence of oxygen and cause burns or fire. A water-based lubricant should be used instead.

A. Polyuria B. Hypoglycemia C. Hypertension D. Oral candidiasis

Correct Answer is D

Explanation

Oral candidiasis, also known as thrush, is a fungal infection of the mouth caused by Candida albicans. It is a common adverse eﬀect of inhaled corticosteroids, such as ﬂuticasone, which can suppress the normal ﬂora of the oral cavity and create a favorable environment for fungal growth. It manifests as white patches or plaques on the tongue, palate, or cheeks that can be scraped oﬀ.

a) Polyuria, or excessive urination, is not an adverse eﬀect of ﬂuticasone. It can be caused by diabetes mellitus, diabetes insipidus, diuretics, or kidney disease.
b) Hypoglycemia, or low blood glucose level, is not an adverse eﬀect of ﬂuticasone. It can be caused by
insulin overdose, oral hypoglycemic agents, alcohol intake, or prolonged fasting.
c) Hypertension, or high blood pressure, is not an adverse eﬀect of ﬂuticasone. It can be caused by stress, obesity, smoking, salt intake, or kidney disease.

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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

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take?

Correct Answer is B

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Correct Answer is D

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