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

This response is empathetic and therapeutic, as it acknowledges the client's feelings and invites her to express her concerns. It also shows respect and interest in the client's perspective.

a) This response is false reassurance and nontherapeutic, as it dismisses the client's feelings and implies

that the surgery will solve everything.

b) This response is self-disclosure and nontherapeutic, as it shifts the focus from the client to the nurse and

does not address the client's fears.

d) This response is minimizing and nontherapeutic, as it tells the client how to feel and does not acknowledge the client's regret or anxiety.

A. Hyperextended position B. Neutral position C. Extended position D. Flexed position

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.

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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

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