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 C
Explanation
A. The head of the bed should be elevated to at least 30-45 degrees to help prevent aspiration and reduce the risk of ventilator-associated pneumonia (VAP). Flat positioning increases the risk of aspiration and subsequent pneumonia.
B. Humidification is important for preventing drying of the respiratory passages but does not directly reduce the risk of VAP.
C. Turning the client every 2 hours (not just 4) is a key practice to prevent VAP by improving lung expansion, promoting drainage, and reducing the risk of ventilator-associated pneumonia.
D. Oral care, including brushing the teeth, should be done more frequently than every 12 hours. The current guidelines recommend brushing the client's teeth every 4-6 hours and using suctioning as needed to prevent oral bacterial buildup that can lead to VAP.
Correct Answer is C
Explanation
A. The client exhales as the medication is released from the inhaler: This is incorrect. The client should inhale deeply while activating the inhaler. Exhaling before inhaling will reduce the effectiveness of the medication.
B. The client takes a quick inhalation while releasing the medication from the inhaler: This is incorrect. The client should inhale slowly and deeply to allow the medication to reach the lungs effectively. A quick inhalation may result in less medication being delivered to the lungs.
C. The client holds his breath for 10 seconds after inhaling the medication: This is the correct action. Holding the breath allows the medication to settle in the lungs, enhancing its therapeutic effect.
D. The client waits 10 min between inhalations: This is not necessary unless instructed by the healthcare provider. Most guidelines suggest waiting 1 to 2 minutes between inhalations of the same medication.
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