Following a motor vehicle accident, a client with chest trauma receives a chest tube to relieve a hemothorax. Two hours following the chest tube insertion, the nurse observes the water level in the water-seal chamber is rising during inspiration and falling during expiration. Which action should the nurse implement?
Lift and clear drainage from the chest tube.
Inspect the tube insertion site for leaking.
Continue to monitor the drainage system.
Auscultate lungs for unequal breath sounds.
The Correct Answer is C
Choice A reason: Lifting and clearing drainage from the chest tube is not necessary, as the water level fluctuations indicate that the chest tube is functioning properly and allowing air and fluid to escape from the pleural space.
Choice B reason: Inspecting the tube insertion site for leaking is not indicated, as there is no evidence of air leak in the water-seal chamber. An air leak would cause continuous or intermittent bubbling in the water-seal chamber.
Choice C reason: Continuing to monitor the drainage system is the best action for the nurse to implement, as the water level fluctuations are normal and expected in a water-seal drainage system. The water level should rise during inspiration and fall during expiration, reflecting the changes in intrathoracic pressure.
Choice D reason: Auscultating lungs for unequal breath sounds is not relevant, as it does not address the question of what to do with the water level fluctuations. Unequal breath sounds may indicate a pneumothorax or atelectasis, which are complications of chest trauma or chest tube insertion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A reason: Presenting a calm, supportive demeanor is an appropriate intervention for a client who is experiencing anxiety and hallucinations. The nurse should use a soothing tone of voice, maintain eye contact, and avoid arguing or challenging the client's perceptions. This can help reduce the client's agitation and promote trust.
Choice B reason: Reorienting to day and time frequently is an appropriate intervention for a client who is experiencing anxiety and hallucinations. The nurse should provide reality-based information and reminders about the client's situation, such as the reason for hospitalization, the name of the nurse, and the expected plan of care. This can help the client regain a sense of orientation and control.
Choice C reason: Administering an as needed (PRN) dose of lorazepam is an appropriate intervention for a client who is experiencing anxiety and hallucinations. Lorazepam is a benzodiazepine that can reduce anxiety, agitation, and psychotic symptoms by enhancing the effects of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter in the brain. The nurse should monitor the client's vital signs, level of sedation, and risk of falls after giving the medication.
Choice D reason: Turning the television on for distraction is not an appropriate intervention for a client who is experiencing anxiety and hallucinations. The television can increase the sensory stimulation and confusion for the client, and may worsen the hallucinations or delusions. The nurse should provide a quiet and safe environment for the client.
Choice E reason: Applying soft wrist restraints bilaterally is not an appropriate intervention for a client who is experiencing anxiety and hallucinations. Restraints can increase the anxiety and agitation for the client, and may cause physical or psychological harm. The nurse should use restraints only as a last resort when other less restrictive measures have failed to protect the client or others from harm.
Correct Answer is A
Explanation
Choice A reason: Sodium polystyrene sulfonate is a medication that binds to excess potassium in the gastrointestinal tract and removes it from the body through feces. It is used to treat hyperkalemia, which is a high level of potassium in the blood. Hyperkalemia can cause cardiac arrhythmias and muscle weakness, and it is a common complication of AKI. Therefore, this medication should be administered first to lower the potassium level and prevent life-threatening complications.
Choice B reason: Sevelamer is a medication that binds to phosphorus in the gastrointestinal tract and removes it from the body through feces. It is used to treat hyperphosphatemia, which is a high level of phosphorus in the blood. Hyperphosphatemia can cause bone loss and soft tissue calcification, and it is a common complication of chronic kidney disease (CKD). However, it is not an urgent issue in AKI, and it does not affect the potassium level.
Choice C reason: Calcium acetate is a medication that also binds to phosphorus in the gastrointestinal tract and removes it from the body through feces. It has the same effect and indication as sevelamer, but it also provides calcium supplementation. However, it is not an urgent issue in AKI, and it does not affect the potassium level.
Choice D reason: Epoetin alfa, recombinant is a medication that stimulates the production of red blood cells in the bone marrow. It is used to treat anemia, which is a low level of hemoglobin or red blood cells in the blood. Anemia can cause fatigue, weakness, and shortness of breath, and it is a common complication of CKD and AKI. However, it is not an urgent issue in AKI, and it does not affect the potassium level.
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