A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?
Continue to monitor the client's respiratory status.
Check the suction control outlet on the wall.
Clamp the chest tube.
Check the tubing connections for leaks.
The Correct Answer is A
Choice A Reason: This choice is correct because slow, steady bubbling in the suction control chamber indicates that the suction is working properly and maintaining a negative pressure in the pleural space. The nurse should continue to monitor the client's respiratory status, such as breath sounds, oxygen saturation, and respiratory rate, to assess the effectiveness of the chest drainage system.
Choice B Reason: This choice is incorrect because checking the suction control outlet on the wall is not necessary unless there is no bubbling in the suction control chamber, which would indicate a problem with the suction source or setting. The nurse should ensure that the suction control outlet is set at the prescribed level, usually between 10 and 20 cm H2O.
Choice C Reason: This choice is incorrect because clamping the chest tube is not indicated unless there is a leak in the system or the chest drainage unit needs to be changed. Clamping the chest tube may cause a buildup of air or fluid in the pleural space, which can lead to tension pneumothorax or pleural effusion.
Choice D Reason: This choice is incorrect because checking the tubing connections for leaks is not necessary unless there is continuous bubbling in the water seal chamber, which would indicate an air leak in the system. The nurse should ensure that all tubing connections are tight and secure, and tape any loose connections.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: This is correct because a pulmonary artery catheter is a device that measures the pressures and flows in the heart and lungs, such as the pulmonary artery pressure, the pulmonary artery wedge pressure, the cardiac output, and the mixed venous oxygen saturation. These parameters reflect the hemodynamic status of the client, which is the balance between the cardiac output and the systemic vascular resistance.
Choice B Reason: This is incorrect because a pulmonary artery catheter does not measure spinal cord perfusion, which is the blood flow to the spinal cord. Spinal cord perfusion can be affected by spinal cord injury, spinal anesthesia, or spinal surgery.
Choice C Reason: This is incorrect because a pulmonary artery catheter does not measure renal function, which is the ability of the kidneys to filter waste products and maintain fluid and electrolyte balance. Renal function can be assessed by urine output, blood urea nitrogen, creatinine, and glomerular filtration rate.
Choice D Reason: This is incorrect because a pulmonary artery catheter does not measure intracranial pressure, which is the pressure inside the skull. Intracranial pressure can be increased by brain injury, stroke, tumor, infection, or hydrocephalus.
Correct Answer is B
Explanation
Choice A Reason: This choice is incorrect because administering a vasodilator medication may lower the blood pressure and worsen the cerebral perfusion. A vasodilator medication is a drug that relaxes the blood vessels and reduces the resistance to blood flow. It may be used for clients who have hypertension, angina, or heart failure, but it does not help to reduce the intracranial pressure (ICP).
Choice B Reason: This choice is correct because elevating the head of the bed to 30° may help to improve the venous drainage and decrease the ICP. ICP is the pressure exerted by the brain tissue, cerebrospinal fluid (CSF), and blood within the cranial cavity. A normal ICP range is 5 to 15 mm Hg, and an elevated ICP (>20 mm Hg) can cause cerebral ischemia, herniation, or death. Therefore, positioning the client in a semi-Fowler's position (30° angle) or high- Fowler's position (60° to 90° angle) can facilitate breathing and prevent further complications.
Choice C Reason: This choice is incorrect because applying a cold compress to the forehead may cause vasoconstriction and increase the ICP. A cold compress is a device that applies cold temperature to a body part to reduce inflammation, pain, or swelling. It may be used for clients who have headaches, sprains, or bruises, but it does not help to reduce the ICP.
Choice D Reason: This choice is incorrect because decreasing the oxygen flow rate may cause hypoxia and worsen the cerebral ischemia. Hypoxia is a condition in which the body or a part of it does not receive enough oxygen. It may cause symptoms such as confusion, agitation, or cyanosis. Therefore, providing adequate oxygenation and ventilation is essential to maintain the brain function and prevent further damage.
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