While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of the patient's closed chest-drainage system. What should the nurse conclude?

A) The system is functioning normally.
B) The patient has a pneumothorax.
C) The system has an air leak.
D) The chest tube is obstructed.


Ans: C
Feedback:
Constant bubbling in the chamber often indicates an air leak and requires immediate assessment and intervention. The patient with a pneumothorax will have intermittent bubbling in the water-seal chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.

Nursing

You might also like to view...

A mother tells the nurse that her child is a picky eater. The nurse responds to the mother, telling her that she should be most concerned if the toddler

a. dislikes food that she once craved. b. puts some of the mother's breath mints in her mouth. c. eats only crackers and milk for 3 days. d. refuses to eat a food the older brother dislikes.

Nursing

A woman has screened positive for intimate partner violence (IPV). The nurse should also assess for (Select all that apply.)

a. depression and anxiety. b. mania and binge behavior. c. persistent sleep disturbances. d. posttraumatic stress disorder (PTSD). e. psychosis and schizophrenia.

Nursing

The emergency department nurse is caring for an infant age 2 months who was brought in by a hired caregiver. The infant is underweight and looks uncared for

The caregiver reports that the mother of the infant is unreliable and may be using drugs; the infant is often unclean and hungry when dropped off at the caregiver's home. The infant has diaper rash and a weak cry. If this situation is not remedied, what will this infant have difficulty achieving, according to Erikson's developmental theory? A) Trust B) Autonomy C) Initiative D) Identity

Nursing

The nurse has completed medication education for the client receiving danazol (Danocrine). The nurse evaluates learning has been effective when the client makes which statements?

1. "I may develop acne while on this medication." 2. "I need to weigh myself twice weekly." 3. "This medication may cause my hair to thin." 4. "I need to have my serum cholesterol levels checked frequently." 5. "I may notice that my breasts enlarge while taking this medication."

Nursing