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A nurse is collecting data from a client who has a new chest tube that is attached to closed chest water-seal drainage and suction. The nurse should report which of the following findings to the charge nurse?

A.

Continuous bubbling in the water-seal chamber

B.

Patient respiratory status is stable and denies pain to chest tube site!

C.

Tidalling, fluctuations in the fluid level in the water-seal chamber

D.

Occasional bubbling in the water-seal chamber

Answer and Explanation

The Correct Answer is A

A. Continuous bubbling in the water-seal chamber: Continuous bubbling in the water-seal chamber indicates a possible air leak in the system, which needs to be assessed and potentially reported to the charge nurse for further evaluation.

B. Patient respiratory status is stable and denies pain to chest tube site: This is a normal finding and does not require reporting.

C. Tidalling, fluctuations in the fluid level in the water-seal chamber: This is a normal finding, indicating that the chest tube is functioning properly and that the lungs are expanding.

D. Occasional bubbling in the water-seal chamber: This may be acceptable, especially with respiratory movements, as it could indicate that the patient is exhaling, but continuous bubbling is concerning.


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Related Questions

Correct Answer is A

Explanation

A. Continuous bubbling in the water-seal chamber: Continuous bubbling in the water-seal chamber indicates a possible air leak in the system, which needs to be assessed and potentially reported to the charge nurse for further evaluation.

B. Patient respiratory status is stable and denies pain to chest tube site: This is a normal finding and does not require reporting.

C. Tidalling, fluctuations in the fluid level in the water-seal chamber: This is a normal finding, indicating that the chest tube is functioning properly and that the lungs are expanding.

D. Occasional bubbling in the water-seal chamber: This may be acceptable, especially with respiratory movements, as it could indicate that the patient is exhaling, but continuous bubbling is concerning.

Correct Answer is C

Explanation

A. Plan to administer insulin to the client: Insulin is not indicated for respiratory alkalosis; it is used for managing hyperglycemia in diabetic patients.

B. Plan to administer sodium bicarbonate to the client: Sodium bicarbonate is not appropriate for respiratory alkalosis and could worsen the condition.

C. Have the client breathe into a paper bag: Breathing into a paper bag can help increase carbon dioxide levels in the blood, which is often helpful in treating respiratory alkalosis due to hyperventilation.

D. Have the client place their head between their knees: This position does not directly address hyperventilation or help regulate breathing.

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