The nurse is taking care of a 60-year-old client with constant bubbling in the water seal chamber. The nurse knows that constant bubbling in the water seal of a chest drainage system indicates which problem?

Air leak

Tension pneumothorax

Kink in the tubing

Increased drainage

Tidaling

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Constant bubbling in the water seal chamber of a chest drainage system typically indicates an air leak. This can occur if there is a break in the system, allowing air to enter. The air leak could be from the chest tube insertion site, the tubing, or the drainage system itself. Identifying and correcting the source of the air leak is crucial to ensure the system functions properly and the patient’s condition does not worsen.

Choice B Reason:

A tension pneumothorax is a life-threatening condition where air accumulates in the pleural space and cannot escape, leading to increased pressure on the lungs and other thoracic structures. While a tension pneumothorax can cause significant respiratory distress, it is not typically indicated by constant bubbling in the water seal chamber. Instead, signs of tension pneumothorax include tracheal deviation, hypotension, and severe respiratory distress.

Choice C Reason:

A kink in the tubing of a chest drainage system can obstruct the flow of air and fluid, but it does not cause constant bubbling in the water seal chamber. Instead, a kink would likely result in a lack of drainage or intermittent bubbling as the obstruction temporarily blocks and then allows passage of air or fluid.

Choice D Reason:

Increased drainage in a chest tube system indicates that more fluid or air is being removed from the pleural space, but it does not cause constant bubbling in the water seal chamber. Increased drainage might be seen in cases of hemothorax or pleural effusion, where large amounts of fluid are present.

Choice E Reason:

Tidaling refers to the normal rise and fall of water in the water seal chamber with the patient’s respiratory cycle. It indicates that the chest tube is patent and functioning correctly. Absence of tidaling could suggest that the lung has fully re-expanded or that there is an obstruction in the system. However, tidaling itself does not cause constant bubbling.

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Correct Answer is ["B","C","D"]

Explanation

Choice A Reason:

Administering 0.45% NS (normal saline) at 50 mL/h is not appropriate for a client with SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion). This solution is hypotonic and can exacerbate the condition by increasing water retention and worsening hyponatremia. Therefore, this choice is not included in the plan of care.

Choice B Reason:

Obtaining daily weight is crucial for monitoring fluid balance in clients with SIADH. Daily weights help detect fluid retention or loss, which is essential for managing the condition. Accurate weight measurements can indicate changes in fluid status and guide adjustments in treatment.

Choice C Reason:

Maintaining seizure precautions is vital for clients with SIADH because severe hyponatremia can lead to neurological symptoms, including seizures. Implementing seizure precautions helps ensure the client’s safety and allows for prompt intervention if seizures occur.

Choice D Reason:

Administering 3% saline as ordered is appropriate for treating severe hyponatremia in clients with SIADH. Hypertonic saline helps increase serum sodium levels, which is critical for correcting the electrolyte imbalance. This intervention should be closely monitored to avoid rapid changes in sodium levels.

Choice E Reason:

Encouraging fluid intake is not appropriate for clients with SIADH. The condition is characterized by excessive water retention, and increasing fluid intake can worsen hyponatremia. Instead, fluid restriction is typically recommended to manage the condition effectively.

A. Administer levetiracetam intravenously. B. Obtain a STAT electroencephalogram. C. Administer lorazepam intravenously. D. Obtain a STAT 12-lead electrocardiogram.

Correct Answer is C

Explanation

Choice A Reason:

Administering levetiracetam intravenously is not the first intervention. While levetiracetam is an antiepileptic drug used to control seizures, it is not the first-line treatment for an ongoing seizure, especially one lasting as long as 15 minutes. The priority in this situation is to stop the seizure activity immediately to prevent further complications, such as neuronal damage or status epilepticus. Levetiracetam may be used later for maintenance therapy, but it is not the initial emergency intervention.

Choice B Reason:

Obtaining a STAT electroencephalogram (EEG) is important for diagnosing and understanding the type of seizure activity, but it is not the first intervention. The immediate priority is to stop the seizure. An EEG can be performed after the seizure has been controlled to assess brain activity and guide further treatment. Delaying the administration of an anticonvulsant to perform an EEG could result in prolonged seizure activity and increased risk of complications.

Choice C Reason:

Administering lorazepam intravenously is the most appropriate first intervention. Lorazepam is a benzodiazepine that acts quickly to stop seizure activity. It is the drug of choice for treating status epilepticus and prolonged seizures because of its rapid onset and effectiveness. Administering lorazepam helps to quickly terminate the seizure, reducing the risk of complications and stabilizing the patient for further evaluation and treatment.

Choice D Reason:

Obtaining a STAT 12-lead electrocardiogram (ECG) is not the first intervention. While an ECG can provide valuable information about the patient’s cardiac status, it does not address the immediate need to stop the seizure. The priority is to administer an anticonvulsant to terminate the seizure. Once the seizure is controlled, an ECG can be performed to assess any potential cardiac issues, especially if the patient has a history of cardiac problems or if the seizure was triggered by a cardiac event.

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The nurse is taking care of a 60-year-old client with constant bubbling in the water seal chamber. The nurse knows that constant bubbling in the water seal of a chest drainage system indicates which problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning care for a client diagnosed with SIADH. Which of the following would be included in the plan of care? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

An adult client who has been experiencing a seizure for approximately 15 minutes is brought to the emergency department by private vehicle. Which intervention should the nurse implement first?

Correct Answer is C

Explanation

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