The nurse is examining a chest drainage system on a patient with a pneumothorax and notes the water level in the water seal chamber fluctuating with each of the patient's respirations. How should the nurse respond?
a. Examine the entire system and tubing for leaks.
b. Clamp the tubing and call for help.
c. Have the patient take a deep breath.
d. No action is necessary; this is an expected finding.
ANS: D
Tidaling is an expected finding. Tubing is sometimes clamped to find an air leak—vigorous bubbling, not tidaling, would signify an air leak. Having the patient take a deep breath can worsen the pneumothorax if a leak is present.
You might also like to view...
The charge nurse, who is a member of Generation X, is training a new nurse, who happens to belong to the Millennial generation. Which aspects of the two nurses' work ethics may be in conflict?
Select all that apply. A) Self-directed versus need for feedback B) Loyal to profession versus rush of new challenges and opportunities C) Workaholic versus need for work-life balance D) Respect authority versus questioning authority E) Prefer personal form of communication versus personal cell phones
SBAR communication stands for __________
a. situation, breathing, airway, and respirations b. situation, background, assessment, and recommendation c. situation, background, action, and recommendation d. situation, breathing, assessment, and recommendation
What code is assigned as an additional diagnosis for patients receiving preoperative evaluations
What will be an ideal response?
During a history a client complains of itching, swelling, and drainage from the eyes with a postnasal drip and sneezing. What type of nasal drainage does the nurse anticipate seeing during inspection of this client's nares?
a. Clear b. Malodorous c. Yellow d. Greenish