A nurse is collecting data from a client who has a new chest tube that is attached to closed chest water-seal drainage and suction. The nurse should report which of the following findings to the charge nurse?
Continuous bubbling in the water-seal chamber
Patient respiratory status is stable and denies pain to chest tube site!
Tidalling, fluctuations in the fluid level in the water-seal chamber
Occasional bubbling in the water-seal chamber
The Correct Answer is A
A. Continuous bubbling in the water-seal chamber: Continuous bubbling in the water-seal chamber indicates a possible air leak in the system, which needs to be assessed and potentially reported to the charge nurse for further evaluation.
B. Patient respiratory status is stable and denies pain to chest tube site: This is a normal finding and does not require reporting.
C. Tidalling, fluctuations in the fluid level in the water-seal chamber: This is a normal finding, indicating that the chest tube is functioning properly and that the lungs are expanding.
D. Occasional bubbling in the water-seal chamber: This may be acceptable, especially with respiratory movements, as it could indicate that the patient is exhaling, but continuous bubbling is concerning.
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Correct Answer is B
Explanation
A. Perform chest physiotherapy prior to suctioning: While chest physiotherapy helps mobilize secretions, it does not thin them, which is the main concern in this situation.
B. Provide humidified oxygen. Humidified oxygen helps to moisten secretions, making them easier to expectorate or suction, which is especially important for tracheostomy care.
C. Pre-lubricate the suction catheter tip with sterile saline when suctioning the airway: This is not a method to thin secretions, but rather to lubricate the catheter.
D. Hyperventilate the client with 100% oxygen before suctioning the airway: This is done to prevent hypoxia during suctioning but does not help with thinning secretions.
Correct Answer is C
Explanation
A. "I will hold the inhaler with my non-dominant hand.": The hand used to hold the inhaler is not as important as the technique for inhaling the medication.
B. "I will tilt my head forward while inhaling the medication.": The head should be in a neutral or slightly tilted back position to ensure proper inhalation of the medication.
C. "I will hold my breath at least 10 seconds after inhaling the medication." Holding the breath for at least 10 seconds allows the medication to be deposited more effectively in the airways, increasing its therapeutic effect.
D. "I will wait 10 min between each inhalation.": The correct time to wait between puffs is usually about 1-2 minutes, not 10 minutes.