The nurse fills the suction control chamber with water to the 20 cm-line while setting up a water-seal chest drainage system. Which rationale does the nurse use to explain this intervention?
1. Creates a method for counting respirations
2. Compensates for leaks in tubing connections
3. Maintains up to 20 cm of intrapleural pressure
4. Facilitates bubbling for pressure over 20 mm Hg
3
3. Lungs inflate as a result of negative intrapleural pressure pulling parenchymal tissue to the chest wall and a thin layer of serous fluid holding it to the chest wall. Twenty cm of water in the water-seal chamber limits negative intrapleural pressure to 20 cm and prevents parenchymal tissue damage; the water prevents positive pressure from entering the intrapleural space and compressing the lungs. Positive pressure destroys negative intrapleural pressure.
1. Respirations are counted by watching the chest rise and fall.
2. Compensatory mechanisms for leaking within the system do not exist; the only remedy is to tighten the connections.
4. Bubbling occurs with an air leak in the WSD system.
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A patient from the Mexican culture tells the nurse that an illness has been caused by mal ojo or "bad eye." How did this health problem occur?
A. Excessive admiration from someone else B. Having a spell caused by black magic C. Being touched improperly by a health care provider D. Lying about the amount of food one has eaten
The patient tells the nurse, "I want to die.". Which is the best response by the nurse to facilitate therapeutic communication?
a. "Now why would you say a thing like that?" b. "Tell me more about how you're feeling.". c. "We need to tell the provider how you feel.". d. "You have too much to live for to say that.".
Identify the dose indicated on the syringe
What will be an ideal response?
A nursery nurse is assessing a newborn. A normal assessment finding is:
1. The child lifting its head off of the mattress. 2. Head lag is present. 3. Holding hands in an open position. 4. Placing a toy in the mouth.