Week 10 PrepU 210

The nurse is caring for a patient following a wedge resection. While the nurse is assessing the patient's chest tube drainage system, constant bubbling is noted in the water seal chamber. This finding indicates which of the following problems?

Air leak Explanation: The nurse needs to observe for air leaks in the drainage system; they are indicated by constant bubbling in the water seal chamber, or by the air leak indicator in dry systems with a one-way valve. Tidaling is fluctuation of the water level in the water seal that shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent.

Which would the nurse most likely expect as treatment for a pneumothorax?

Chest tube insertion Explanation: Chest tube insertion would be important for a pneumothorax to restore the negative pressure. Anti-infective therapy would be appropriate for an infection. Control of allergen exposure would be appropriate for asthma. Surfactant replacement would be appropriate for respiratory distress syndrome.

A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which of the following delivery devices should the nurse use in order to administer oxygen to the client?

Nasal cannula Explanation: The nurse should use a nasal cannula to administer oxygen to an asthmatic client who requires a low concentration of oxygen. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It is used for administering a low concentration of oxygen to clients who are not extremely hypoxic and are diagnosed with chronic lung disease. A simple mask allows the administration of higher levels of oxygen than a cannula. A face tent is used for clients with facial trauma and burns. Non-rebreather masks are used for clients requiring a high concentration of oxygen and are critically ill.

Which assessment factors would indicate a need for oropharyngeal suctioning?

breathing rate of 36 breaths/min and noisy, gurgling respirations Explanation: An increase in the breathing rate indicates hypoxia in the body. The signs of noisy, gurgling respirations indicate airway interference and the need for suctioning. Clients should be able to cough up thin sputum, and tonsil enlargement should not interfere. Crackles in lower lobes signify lung congestion, not airway impairment. Oxygen saturation levels of 95% are normal.

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?

measuring and documenting the drainage in the collection chamber Explanation: The nurse should regularly measure and document the amount of chest tube drainage to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected. The nurse should keep the collection chamber below chest level to allow fluids to drain into it. The nurse shouldn't strip chest tubes because doing so may traumatize the tissue or dislodge the tube.