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.
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Related Questions
Correct Answer is D
Explanation
A. Ambulating frequently helps with overall circulation and lung expansion but does not directly affect the thinning of respiratory secretions.
B. Coughing and deep breathing help clear secretions but are not effective for thinning them.
C. The incentive spirometer is used to improve lung expansion and prevent atelectasis, but it does not directly thin secretions.
D. Increasing fluid intake helps thin respiratory secretions by providing hydration, which makes mucus easier to clear from the respiratory tract.
Correct Answer is A
Explanation
A. In SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion), the body retains excessive water, leading to dilutional hyponatremia (low sodium levels). Administering hypertonic saline (3% NS) can exacerbate the condition by rapidly increasing sodium levels, which may cause demyelination of neurons (a condition called osmotic demyelination syndrome). Hypertonic saline is typically only used in severe hyponatremia with neurologic symptoms and should be carefully monitored.
B. Seizure precautions are appropriate in SIADH due to the risk of seizures from severe hyponatremia, which can lead to cerebral edema and neurological compromise.
C. Fluid restriction of 1000 mL/day is appropriate in SIADH to manage the dilutional hyponatremia by preventing further fluid retention.
D. A sodium-restricted diet is also recommended in SIADH to avoid further dilution of sodium levels and prevent worsening of hyponatremia.
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