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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Have the client refrain from talking for 24 hr: The client only needs to refrain from talking until the anesthesia wears off, usually within an hour. There is no need to refrain from talking for 24 hours.
B. Withhold food and liquids until the client's gag reflex returns: This is the correct action. Following a bronchoscopy, the local anesthetic used can suppress the gag reflex. It is crucial to wait until the gag reflex returns to prevent aspiration when the client eats or drinks. C. Irrigate the client's throat every 4 hr: There is no indication to irrigate the throat routinely. The priority is to ensure that the gag reflex has returned before allowing oral intake.
D. Suction the client's oropharynx frequently: Suctioning is only necessary if the client is unable to clear their secretions or has difficulty breathing. It is not a standard post-procedure intervention.

A. "It is caused by the lack of production of insulin by the pancreas." B. "It is caused by the overproduction of parathormone by the parathyroid gland." C. "It is caused by the lack of production of aldosterone by the adrenal gland." D. "It is caused by the overproduction of growth hormone by the pituitary gland."

Correct Answer is C

Explanation

A. "It is caused by the lack of production of insulin by the pancreas.": This is incorrect. The lack of insulin production causes diabetes mellitus, not Addison’s disease. Addison’s disease results from insufficient production of adrenal hormones, particularly aldosterone and cortisol.
B. "It is caused by the overproduction of parathormone by the parathyroid gland.": This is incorrect. Parathormone is produced by the parathyroid glands and regulates calcium balance, but overproduction of parathormone leads to conditions such as hyperparathyroidism, not Addison’s disease.
C. "It is caused by the lack of production of aldosterone by the adrenal gland.": This is correct. Addison’s disease, also known as primary adrenal insufficiency, is caused by the inability of the adrenal glands to produce sufficient aldosterone and cortisol, two critical hormones. Aldosterone helps regulate sodium and potassium balance, and cortisol helps the body respond to stress.
D. "It is caused by the overproduction of growth hormone by the pituitary gland.": This is incorrect. Overproduction of growth hormone causes acromegaly or gigantism, not Addison’s disease. Addison’s disease results from adrenal insufficiency, not pituitary gland dysfunction.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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