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. Formoterol is a long-acting beta agonist (LABA) used for maintenance therapy, not for aborting acute asthma attacks. LABAs help prevent asthma symptoms but are not effective for immediate relief during an acute attack.
B. Albuterol is a short-acting beta agonist (SABA), which is the medication of choice for relieving acute asthma symptoms. It acts quickly to relax the muscles of the airways and relieve bronchospasm.
C. Beclomethasone is an inhaled corticosteroid used for long-term asthma control, reducing inflammation, but it is not used to treat acute attacks.
D. Salmeterol is another LABA, similar to formoterol, and is not used for aborting acute asthma attacks but rather for long-term control.
Correct Answer is B
Explanation
A. While avoiding infection is important for individuals with Addison's disease due to their weakened immune system, the priority is ensuring proper medication management.
B. Managing lifelong corticosteroid replacement is the most crucial instruction because individuals with Addison's disease have insufficient production of adrenal hormones, particularly cortisol. Without appropriate corticosteroid therapy, they can experience life-threatening adrenal crises.
C. Wearing a Medic-Alert bracelet is a helpful precaution, but it is not as immediately critical as ensuring proper medication management.
D. Practicing stress-management techniques is beneficial, as stress can exacerbate symptoms of Addison's disease, but corticosteroid replacement remains the highest priority.
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