The nurse suspects which cause of increased bubbling in the water seal chamber of a patient's chest drainage unit?
The patient has a pleural friction rub.
The patient has an infection at the drainage site.
The patient has a bronchopleural leak.
The patient has complete lung re-expansion.
The Correct Answer is C
A. A pleural friction rub occurs when the pleural surfaces rub against each other, usually due to inflammation, but it does not directly cause increased bubbling in the water seal chamber of a chest drainage unit.
B. An infection at the drainage site could lead to localized symptoms like redness or discharge, but it does not directly cause increased bubbling in the water seal chamber.
C. A bronchopleural leak is the most likely cause of increased bubbling in the water seal chamber. This occurs when there is an air leak between the lungs and pleural space, causing continuous air to enter the chest drainage system.
D. Complete lung re-expansion would not typically cause bubbling in the water seal chamber. Once the lung is fully re-expanded, bubbling should stop.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While tissue integrity is important, the primary concern immediately postoperatively for a patient who has undergone a partial laryngectomy is ensuring that the airway is open and clear.
B. Airway patency should be assessed first because this surgery involves the upper airway structures, and complications such as obstruction, swelling, or bleeding could compromise the airway and lead to respiratory distress.
C. Pain severity should be assessed as part of routine care, but airway patency takes precedence to prevent respiratory complications.
D. Wound drainage should be monitored but does not take priority over airway assessment in the immediate postoperative period.
Correct Answer is D
Explanation
A. While documenting the amount of drainage is important, it is not the most urgent action when clear drainage is observed after a transsphenoidal hypophysectomy.
B. Notifying the provider is important but should not be the first step. The nurse should first assess the nature of the drainage, as it could indicate a serious complication, such as cerebrospinal fluid (CSF) leakage.
C. A culture may be necessary if infection is suspected, but the priority action is to assess whether the drainage is CSF.
D. Checking the drainage for glucose is the most appropriate initial action. Clear drainage from the nasal packing could indicate a CSF leak, which is a complication that can occur after transsphenoidal surgery. CSF contains glucose, so testing for glucose in the drainage will help determine if it is CSF. If glucose is detected, the nurse should immediately notify the provider, as CSF leakage requires prompt intervention.
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