A nurse is collecting data on a client who has respiratory alkalosis. Which of the following findings should the nurse expect?
Abdominal pain
Hyperventilation
constipation
Dry skin
The Correct Answer is B
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).
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Correct Answer is A
Explanation
A. Maintain the drainage container below the level of the client's chest. Keeping the drainage container below the level of the client's chest allows gravity to assist in draining fluid or air from the pleural space and prevents backflow into the chest.
B. Add tap water as needed to the suction control chamber: This is incorrect; sterile water should be used, not tap water, to prevent contamination.
C. Clamp the chest tubes if it becomes disconnected: This is not recommended as clamping can create a tension pneumothorax. Instead, the nurse should use a sterile gauze to cover the site and notify the provider.
D. Empty the collection container every shift: The collection container should be emptied as needed, not on a set schedule, to ensure proper function and accurate measurement of drainage.
Correct Answer is A
Explanation
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.