A nurse is checking the suction control chamber of a client's chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?
Notify the provider.
Verify that the suction regulator is on.
Continue to monitor the client because this is an expected finding.
Milk the chest tube to dislodge any clots in the tubing that may be occluding it.
The Correct Answer is B
A. Notify the provider.
This choice suggests involving the healthcare provider immediately. While notifying the provider might eventually be necessary if the issue persists, it's not the initial action in this scenario. The nurse should first assess and troubleshoot the situation before escalating it to the provider.
B. Verify that the suction regulator is on.
This is the correct choice. When there is no bubbling in the suction control chamber of a chest tube, it may indicate that suction is not being applied properly. Verifying that the suction regulator is turned on and set to the correct level ensures that suction is being delivered to the chest tube.
C. Continue to monitor the client because this is an expected finding.
This choice is incorrect. The absence of bubbling in the suction control chamber is not an expected finding and suggests a potential problem with the suction system. Ignoring this finding without taking any action could lead to complications for the client.
D. Milk the chest tube to dislodge any clots in the tubing that may be occluding it.
Milking the chest tube is a technique used to maintain patency and promote drainage in chest tubes, but it should not be the first action when there is no bubbling in the suction control chamber. This action does not address the underlying issue of inadequate suction and may not be appropriate without first ensuring that suction is functioning correctly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Provide humidified oxygen.
Humidified oxygen adds moisture to the air, which can help to thin secretions in the airway. Thinning the secretions makes them easier to clear, particularly for patients with copious and tenacious secretions, such as those following a tracheostomy.
B. Perform chest physiotherapy prior to suctioning.
Chest physiotherapy techniques, such as percussion and vibration, can help to mobilize secretions in the lungs and airways. While this may indirectly assist in clearing secretions, it does not directly address the issue of thinning the secretions, which is the primary concern in this scenario.
C. Prelubricate the suction catheter tip with sterile saline when suctioning the airway.
Prelubricating the suction catheter tip with sterile saline before suctioning can help reduce friction and potential trauma to the airway. While this can be beneficial for airway management, it does not directly address the need to thin copious and tenacious secretions.
D. Hyperventilate the client with 100% oxygen before suctioning the airway.
Hyperventilating the client with 100% oxygen before suctioning is not recommended. It can lead to respiratory alkalosis, which is a condition characterized by decreased levels of carbon dioxide in the blood. This can worsen the client's condition and may lead to adverse effects. Additionally, it does not directly address the need to thin secretions.
Correct Answer is C
Explanation
A. "I'll rinse my mouth after taking this medication."
Montelukast is taken orally and is not associated with the risk of oral thrush or other mouth-related side effects that would require rinsing the mouth after administration. This action is more commonly associated with inhaled corticosteroids, not leukotriene receptor antagonists.
B. "I'll use this medication when I get an asthma attack."
Montelukast is not a rescue medication for asthma attacks. It is a long-term controller medication used to manage and prevent asthma symptoms, not to treat acute attacks. Short-acting bronchodilators such as albuterol are used for quick relief during asthma attacks.
C. "I'll take this medication once a day in the evening."
Montelukast is a leukotriene receptor antagonist commonly used to manage asthma. It is typically taken orally once daily, usually in the evening, to provide 24-hour control of asthma symptoms and improve lung function. Therefore, the statement indicating an understanding of the teaching is option C.
D. "I'll decrease my sodium intake while I'm taking this medication."
Montelukast is not known to affect sodium levels in the body or require any specific dietary modifications, such as decreasing sodium intake. Therefore, this statement is unrelated to the use of montelukast for asthma management
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