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 D
Explanation
A. Ambulating frequently helps with overall circulation and lung expansion but does not directly affect the thinning of respiratory secretions.
B. Coughing and deep breathing help clear secretions but are not effective for thinning them.
C. The incentive spirometer is used to improve lung expansion and prevent atelectasis, but it does not directly thin secretions.
D. Increasing fluid intake helps thin respiratory secretions by providing hydration, which makes mucus easier to clear from the respiratory tract.
Correct Answer is A
Explanation
A. Tachypnea, or rapid breathing, is a common finding in pneumonia due to hypoxia and the body's attempt to compensate for impaired gas exchange in the lungs. It is one of the hallmark signs of pneumonia.
B. Bradycardia is uncommon in pneumonia. Tachycardia (increased heart rate) is more frequently observed as the body compensates for the infection and reduced oxygenation.
C. Hypothermia is not typically associated with pneumonia; more commonly, fever (hyperthermia) is present as a sign of infection.
D. A pulse deficit is a sign of a heart condition, such as atrial fibrillation, not typically related to pneumonia.
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