A nurse is caring for a client who is 12 hr 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
Continuous bubbling in the water-seal chamber
Fluid-level fluctuations in the water-seal chamber
Bloody drainage in the collection chamber
The Correct Answer is B
A. Constant bubbling in the suction-control chamber is normal as it indicates that the suction is active and functioning as intended. The chamber should have steady bubbling when suction is applied.
B. Continuous bubbling in the water-seal chamber is abnormal and indicates a potential air leak. The water-seal chamber should only bubble intermittently with respiratory effort or changes in pressure; constant bubbling suggests that air is being introduced into the system, which could indicate a malfunction or an air leak at the insertion site or along the tubing.
C. Fluid-level fluctuations in the water-seal chamber are normal and should be observed, especially with breathing. The fluid levels will rise with inspiration and fall with expiration, reflecting the changes in pressure within the pleural space.
D. Bloody drainage in the collection chamber is expected immediately after surgery, particularly in the early postoperative period. It may be a sign of surgical site drainage, but if it becomes excessive or persists, further assessment is required. However, a small amount of blood in the collection chamber initially is not abnormal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While tissue integrity is important, the primary concern immediately postoperatively for a patient who has undergone a partial laryngectomy is ensuring that the airway is open and clear.
B. Airway patency should be assessed first because this surgery involves the upper airway structures, and complications such as obstruction, swelling, or bleeding could compromise the airway and lead to respiratory distress.
C. Pain severity should be assessed as part of routine care, but airway patency takes precedence to prevent respiratory complications.
D. Wound drainage should be monitored but does not take priority over airway assessment in the immediate postoperative period.
Correct Answer is C
Explanation
A. Hypertension is not typically associated with pneumonia, especially in older adults. Pneumonia can lead to hypotension or sepsis, but not usually hypertension.
B. Unequal pupils are not a typical finding associated with pneumonia. This could suggest a neurological issue or a possible eye problem, not a respiratory infection.
C. Confusion is a common sign of pneumonia in older adults, especially in the elderly, who may present with altered mental status due to hypoxia, infection, or dehydration. Delirium or confusion is a common manifestation of pneumonia in this population.
D. Tympany on chest percussion suggests air in the abdominal cavity, not in the lungs, and is not typically associated with pneumonia. Pneumonia is more likely to present with dullness upon percussion due to consolidation in the lungs.
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