A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority?

Assist the client to Fowler's position

Promote removal of pulmonary secretions

Increase the oxygen flow

Obtain a specimen for arterial blood gases

Answer and Explanation

The Correct Answer is A

A. Assist the client to Fowler's position: This position helps maximize lung expansion, making it easier for the client to breathe.
B. Promote removal of pulmonary secretions: Important but secondary to addressing immediate respiratory distress.
C. Increase the oxygen flow: This should only be done per provider order to avoid complications such as oxygen toxicity.
D. Obtain a specimen for arterial blood gases: This is a diagnostic step but not an immediate intervention for difficulty breathing.

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Correct Answer is A

Explanation

A. Continue to monitor the client: A rise in the water seal with inspiration and fall during expiration (tidaling) is normal in a functioning chest tube system and indicates proper lung expansion.
B. Clamp the chest tube near the water seal: Clamping the tube can cause tension pneumothorax and is not appropriate unless specifically instructed by a provider.
C. Reposition the client and recheck the chamber: Repositioning is unnecessary unless there are signs of obstruction or complications.
D. Add water to the chamber: Water addition is only required if the water level falls below the recommended amount, not in response to normal tidaling.

A. clamp the chest tube and place the patient in high Fowler's position B. immediately turn the patient to the side of the insertion site C. document findings D. check for air leaks in drainage system

Correct Answer is D

Explanation

A. Clamp the chest tube and place the patient in high Fowler’s position: Clamping the tube may cause tension pneumothorax and should be done only with a specific prescription.
B. Immediately turn the patient to the side of the insertion site: This action does not address the source of constant bubbling.
C. Document findings: Bubbling in the suction chamber can be normal, but documenting without further assessment may overlook potential system issues.
D. Check for air leaks in the drainage system: Constant bubbling may indicate an air leak, which requires immediate assessment and correction.

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A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following should the nurse do after noticing a rise in the water seal with client inspiration?

Correct Answer is A

Explanation

A nurse caring for a patient with a water seal type chest drainage that is on low suction assesses that there is constant bubbling in the suction container. The nurse should:

Correct Answer is D

Explanation

Which is a function of the respiratory system?

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