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","C","E"]
Explanation
These clients have impaired swallowing, gag reflex, or level of consciousness, which increase their risk of aspiration while eating.
The other options are not correct because:
b. A client who has had prolonged diarrhea does not have a direct risk factor for aspiration, as diarrhea affects the lower gastrointestinal tract and not the upper airway or esophagus.
d. A client who has lactose intolerance does not have a risk factor for aspiration, as lactose intolerance causes abdominal cramps, bloating, gas, or diarrhea when consuming dairy products, but does not affect the ability to swallow or protect the airway.
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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