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. Plan to administer insulin to the client: Insulin is not indicated for respiratory alkalosis; it is used for managing hyperglycemia in diabetic patients.
B. Plan to administer sodium bicarbonate to the client: Sodium bicarbonate is not appropriate for respiratory alkalosis and could worsen the condition.
C. Have the client breathe into a paper bag: Breathing into a paper bag can help increase carbon dioxide levels in the blood, which is often helpful in treating respiratory alkalosis due to hyperventilation.
D. Have the client place their head between their knees: This position does not directly address hyperventilation or help regulate breathing.