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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. Hyperaldosteronism causes sodium retention and potassium excretion, leading to elevated serum sodium levels and low potassium levels. A serum potassium level of 2.5 mmol/L is indicative of hypokalemia, which is a classic finding in hyperaldosteronism.
B. This serum electrolyte pattern (normal sodium and potassium) is not suggestive of hyperaldosteronism.
C. In hyperaldosteronism, the serum sodium is typically elevated, but the potassium level is very low, not elevated as seen in this option.
D. While low potassium is indicative of hyperaldosteronism, the sodium level is abnormally low in this case, which is not typical for this condition. Hyperaldosteronism typically presents with elevated sodium.

A. Position the head of the client's bed in the flat position. B. Provide humidity by maintaining moisture within the ventilator tubing. C. Turn the client every 4 hr. D. Brush the client's teeth with a suction toothbrush every 12 hr.

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.

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The nurse suspects which cause of increased bubbling in the water seal chamber of a patient's chest drainage unit?

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Naxlex Comprehensive Predictor Exams

Which serum electrolyte value alerts the nurse to the possibility of hyperaldosteronism?

Correct Answer is A

Explanation

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator-associated pneumonia?

Correct Answer is C

Explanation

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