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 C
Explanation
A. Provide mouth care: Mouth care is important to prevent infection but is not the first priority in this procedure.
B. Position the client so that the lung area to be drained is above the client’s trachea: This is necessary for effective postural drainage, but auscultation should be done first to determine the area to drain.
C. Auscultate lung fields. Auscultating lung fields first helps to determine the location of secretions and identify which areas of the lungs need to be targeted during postural drainage and percussion.
D. Cup hands and tap on the client’s chest repeatedly: Chest percussion helps mobilize secretions, but it should be done after auscultation to target the correct areas.
Correct Answer is C
Explanation
A. Provide prophylactic antibiotics for clients who have been exposed to influenza: Antibiotics are not effective against viral infections like influenza. Antiviral medications may be used for prophylaxis in exposed individuals.
B. Assign health care personnel to non-direct care activities for 24 hr after developing influenza symptoms: Healthcare personnel should not provide care while symptomatic. The recommended restriction period is typically longer than 24 hours.
C. Place restrictions on visitation. During an influenza outbreak, limiting visitation can reduce the spread of infection, especially in vulnerable populations like those in long-term care facilities.
D. Implement airborne precautions for clients who have influenza: Influenza is spread through droplets, not airborne particles. Droplet precautions are appropriate.