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. Abdominal pain: This is not typically associated with respiratory alkalosis, which primarily affects respiratory and neurologic systems.
B. Hyperventilation: Respiratory alkalosis occurs when a person exhales too much carbon dioxide, typically from hyperventilation, which can result from anxiety, pain, or other conditions.
C. Constipation: This is not a symptom of respiratory alkalosis; it might be seen in other metabolic disorders but not this one.
D. Dry skin: Dry skin is not a common manifestation of respiratory alkalosis; symptoms are usually respiratory and neurological (e.g., lightheadedness, tingling).
Correct Answer is C
Explanation
A. "It delivers the highest concentration of oxygen possible." This is inaccurate; other methods (like non-rebreather masks) deliver higher concentrations.
B. "It delivers a specific concentration of oxygen constantly." While it does provide a specific concentration, it is not as constant as other devices because it can vary based on the client's breathing patterns.
C. "It delivers the low concentration of oxygen you need." A nasal cannula typically delivers a low concentration of oxygen (approximately 24-44% oxygen depending on the flow rate), which is appropriate for clients who need supplemental oxygen but do not require a high concentration.
D. "It allows you to remove it for a while when it gets uncomfortable." This is misleading; while the client can remove it temporarily, it is essential to maintain oxygen therapy as prescribed for adequate oxygenation.