A nurse is caring for a client who is 12 hours postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations?
Constant bubbling in the suction-control chamber.
Bloody drainage in the collection chamber.
Fluid-level fluctuations in the water-seal chamber.
Continuous bubbling in the water-seal chamber.
The Correct Answer is D
Choice A rationale
Constant bubbling in the suction-control chamber is expected and indicates that the suction is functioning properly.
Choice B rationale
Bloody drainage in the collection chamber is expected in the immediate postoperative period and does not require intervention.
Choice C rationale
Fluid-level fluctuations in the water-seal chamber are normal and indicate that the system is functioning properly.
Choice D rationale
Continuous bubbling in the water-seal chamber indicates an air leak and requires intervention to prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A room that is within view of the nurses’ station is not suitable for a client with active tuberculosis. This placement does not provide the necessary isolation to prevent the spread of the infection to other patients and staff. Tuberculosis is an airborne disease, and the client needs to be in a room that minimizes the risk of airborne transmission.
Choice B rationale
A room with another nonsurgical client is also inappropriate for a client with active tuberculosis. Placing the client with another patient increases the risk of transmission of the infection. Tuberculosis requires strict airborne precautions, and the client should be in a private room with appropriate ventilation.
Choice C rationale
A room in the ICU is not necessary unless the client requires intensive care for other reasons. The primary concern for a client with active tuberculosis is to prevent the spread of the infection, which can be effectively managed in a regular medical-surgical unit with proper isolation measures.
Choice D rationale
A room with air exhaust directly to the outdoor environment is the correct choice. This type of room, often referred to as a negative pressure room, ensures that air from the room does not flow to other parts of the facility, thereby preventing the spread of infectious airborne particles. This setup is essential for managing clients with active tuberculosis.
Correct Answer is D
Explanation
Choice A rationale
Reviewing laboratory test results for low hemoglobin is important for monitoring anemia, which can be a side effect of radiation therapy. However, it is not the most immediate action to address the specific side effects of radiation therapy to the lung, such as xerostomia (dry mouth) and skin reactions.
Choice B rationale
Assessing the skin for erythema is important as radiation therapy can cause skin reactions, including redness and irritation. However, this action does not directly address the management of xerostomia, which is a common side effect of radiation therapy to the head and neck areas.
Choice C rationale
Monitoring the client for signs of fatigue is essential as fatigue is a common side effect of radiation therapy. However, this action does not specifically address the management of xerostomia, which requires targeted oral care.
Choice D rationale
Providing oral care to manage xerostomia is the correct action. Xerostomia, or dry mouth, is a common side effect of radiation therapy, especially when the head and neck are involved. Oral care helps to alleviate discomfort, prevent infections, and maintain oral health.
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