Nokea
An adult has a chest drainage system. Several hours after the chest tube was inserted, the nurse observes that there is no bubbling in the water seal chamber. What is the most likely reason for the absence of bubbling?
- A. The client's lungs have reexpanded.
- B. There is an obstruction in the tubing coming from the client.
- C. There is a mechanical problem in the pump.
- D. Air is leaking into the drainage apparatus.
Correct Answer: A
Rationale: No bubbling in the water seal chamber typically indicates lung reexpansion, as air is no longer leaking from the lung into the pleural space.
You may also like to solve these questions
A 52-year old female patient is receiving medical treatment for a possible tuberculosis infection. The patient is a U.S. resident but grew up in a foreign country. She reports that as a child she received the BCG vaccine (bacille Calmette-Guerin vaccine). Which physician's order below would require the nurse to ask the doctor for an order clarification?
- A. PPD (Mantoux test)
- B. Chest X-ray
- C. QuantiFERON-TB Gold (QFT)
- D. Sputum culture
Correct Answer: A
Rationale: The BCG vaccine can cause false-positive PPD (Mantoux) test results, making it unreliable in patients with a BCG history. The nurse should clarify this order, as an IGRA test (e.g., QuantiFERON-TB Gold) or other diagnostics are preferred.
The client is diagnosed with bronchiolitis obliterans. Which data indicate the glucocorticoid therapy is effective?
- A. The client has an elevation in the blood glucose.
- B. The client has a decrease in sputum production.
- C. The client has an increase in the temperature.
- D. The client appears restless and is irritable.
Correct Answer: B
Rationale: Decreased sputum production (B) indicates reduced airway inflammation in bronchiolitis obliterans, suggesting effective glucocorticoid therapy. Elevated glucose (A) is a side effect, not efficacy. Increased temperature (C) or restlessness (D) suggests worsening or side effects, not improvement.
When the nurse is teaching a client to self-administer nose drops, which head position is appropriate?
- A. Bending the head forward, then instilling the drops
- B. Pushing the nose laterally, then instilling the drops
- C. Tilting the head backward, then instilling the drops
- D. Turning the head to the side, then instilling the drops
Correct Answer: C
Rationale: Tilting the head backward allows nose drops to reach the nasal passages effectively by gravity, ensuring proper distribution of the medication.
Which statement by the client would indicate to the nurse that the client has an accurate understanding of the planned surgery?
- A. The surgeon is planning to remove one of my lungs.
- B. Only one lobe of my lung will be removed.
- C. The surgeon will take a sample of my lung tissue to be biopsied during the procedure.
- D. A lung will be opened and examined during surgery.
Correct Answer: A
Rationale: A pneumonectomy involves removing an entire lung, so the client's statement reflects accurate understanding.
Before discharging a client with fractured ribs from the emergency department, which instruction is most important for the nurse to give the client?
- A. Avoid coughing to prevent further injury.
- B. Take deep breaths periodically.
- C. Apply heat to the chest daily.
- D. Sleep in a prone position.
Correct Answer: B
Rationale: Taking deep breaths periodically prevents atelectasis and pneumonia, which are risks with fractured ribs due to shallow breathing.