Nokea
What is the primary nursing action for a patient experiencing continuous bubbling in the chest tube water seal chamber?
- A. Tighten the connections of the chest tube system
- B. Clamp the chest tube
- C. Continue monitoring the chest tube
- D. Replace the chest tube system
Correct Answer: A
Rationale: The correct answer is to tighten the connections of the chest tube system. Continuous bubbling in the chest tube water seal chamber indicates an air leak. By tightening the connections of the chest tube system, the nurse can often resolve the issue by ensuring there are no loose connections allowing air to enter. Clamping the chest tube or replacing the chest tube system are not appropriate actions in this situation. Clamping the tube can cause a dangerous buildup of pressure, while replacing the system should only be considered if tightening the connections does not resolve the air leak.
You may also like to solve these questions
A patient with a new diagnosis of diabetes insipidus is planning care. What should be included in the plan of care?
- A. Avoid alcohol
- B. Increase exercise to reduce stress
- C. Increase fluid intake
- D. Restrict sodium intake
Correct Answer: A
Rationale: The correct answer is to avoid alcohol. In diabetes insipidus, excessive urination leads to fluid loss, so it is essential to avoid alcohol which can exacerbate dehydration. Choice B is incorrect as increasing exercise may not directly impact diabetes insipidus. Choice C is also incorrect because although increasing fluid intake may seem intuitive, it is not the primary concern in managing diabetes insipidus. Choice D is not directly related to managing diabetes insipidus; sodium restriction is more relevant in conditions like hypertension or heart failure.
What is an escharotomy and why is it performed?
- A. A surgical incision made to improve circulation in burn injuries
- B. A procedure to remove dead tissue from a wound
- C. A procedure to remove excess fluid from the lungs
- D. A procedure to relieve pain from burns
Correct Answer: A
Rationale: An escharotomy is a surgical procedure involving an incision through the eschar (dead tissue) to relieve pressure in burn injuries. It is performed to improve circulation to the affected area, prevent further damage, and restore blood flow. Choice B is incorrect because an escharotomy is not primarily focused on removing dead tissue but rather on relieving pressure. Choice C is incorrect as it describes a procedure related to pulmonary issues, not burn injuries. Choice D is incorrect because while pain relief may be a result of an escharotomy, it is not the primary purpose of the procedure.
What should a healthcare provider teach a patient who has experienced an acute episode of gastritis?
- A. Avoid foods high in potassium
- B. Avoid foods high in sodium
- C. Increase exercise to reduce stress
- D. Drink milk as a snack
Correct Answer: A
Rationale: The correct answer is A: Avoid foods high in potassium. During an acute episode of gastritis, it is advisable to avoid foods high in potassium as they can exacerbate symptoms. Potassium-rich foods may irritate the stomach lining, leading to increased discomfort. Choices B, C, and D are incorrect. Avoiding foods high in sodium is not specifically related to managing gastritis. Increasing exercise to reduce stress is a good general recommendation but not directly related to managing gastritis symptoms. Drinking milk as a snack is not recommended for gastritis as dairy products can sometimes worsen symptoms due to their fat content.
What are the expected signs in a patient with compartment syndrome?
- A. Unrelieved pain, pallor, and pulselessness
- B. Fever and infection
- C. Localized redness and swelling
- D. Loss of sensation in the affected area
Correct Answer: A
Rationale: In a patient with compartment syndrome, the classic signs include unrelieved pain, pallor, and pulselessness. These signs indicate compromised circulation and neurovascular function in the affected compartment. Fever and infection (Choice B) are not typical signs of compartment syndrome. Localized redness and swelling (Choice C) can be seen in other conditions like cellulitis but are not specific to compartment syndrome. Loss of sensation in the affected area (Choice D) may occur in some cases but is not as specific or consistent as unrelieved pain, pallor, and pulselessness in diagnosing compartment syndrome.
What is the first action when continuous bubbling is observed in the chest tube water seal chamber?
- A. Tighten the connections of the chest tube system
- B. Clamp the chest tube
- C. Replace the chest tube system
- D. Continue monitoring the chest tube
Correct Answer: A
Rationale: When continuous bubbling is observed in the chest tube water seal chamber, the first action should be to tighten the connections of the chest tube system. This step is crucial as it can often resolve an air leak causing continuous bubbling. Clamping the chest tube or replacing the chest tube system would not address the underlying issue of loose connections and may not be necessary. Continuing to monitor the chest tube without taking corrective action may lead to complications if the air leak is not addressed promptly.