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 A
Explanation
Choice A rationale
Coronary arteries decrease in diameter leading to insufficient blood, oxygen, and nutrients reaching the heart muscle. This is correct because atherosclerosis, which is the buildup of plaque in the coronary arteries, causes the arteries to narrow. This narrowing reduces blood flow to the heart muscle, leading to ischemia and the manifestations of coronary artery disease, such as angina and myocardial infarction.
Choice B rationale
Manifestations occur due to dilation of coronary arteries with increased blood flow causing increased pressure. This is incorrect because the primary issue in coronary artery disease is the narrowing of the arteries, not their dilation. Increased blood flow and pressure are not typical causes of the manifestations of coronary artery disease.
Choice C rationale
Coronary arteries become more elastic causing the arteries to stretch as individuals age causing the heart not to receive enough oxygen. This is incorrect because the problem in coronary artery disease is not increased elasticity but rather the loss of elasticity and the buildup of plaque that narrows the arteries. As people age, the arteries tend to become less elastic, not more.
Choice D rationale
The heart and the coronary arteries weaken, leading to poor perfusion and resulting in angina. This is incorrect because the primary issue in coronary artery disease is the narrowing of the coronary arteries due to plaque buildup, not the weakening of the heart and arteries. While poor perfusion does result in angina, it is due to the narrowed arteries rather than weakened structures.
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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