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
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.
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale
A heart rate of 110/min and regular is not an immediate concern in this context. Tachycardia can occur due to various reasons, including anxiety or pain, and does not require immediate follow-up.
Choice B rationale
Oxygen saturation of 95-96% is within the normal range and does not require immediate follow-up.
Choice C rationale
Subcutaneous emphysema requires immediate follow-up because it indicates air leakage into the subcutaneous tissue, which can be a sign of pneumothorax or other complications.
Choice D rationale
A trachea that is midline does not require immediate follow-up as it indicates there is no mediastinal shift.
Choice E rationale
A dry puncture site does not require immediate follow-up as it indicates there is no ongoing issue at the insertion site.
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