a patient has a chest tube with continuous bubbling in the water seal chamber what does this indicate

ATI RN

ATI Capstone Medical Surgical Assessment 2 Quizlet

1. What does continuous bubbling in the water seal chamber of a chest tube indicate?

A. An air leak
B. A blockage in the chest tube
C. Normal chest tube function
D. Malfunction in the drainage system

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the chest tube system. This bubbling occurs when air is escaping through the tube and entering the water seal chamber. Choice B, a blockage in the chest tube, is incorrect as continuous bubbling does not suggest a blockage. Choice C, normal chest tube function, is incorrect because continuous bubbling is not an expected finding in a properly functioning chest tube. Choice D, a malfunction in the drainage system, is incorrect as continuous bubbling specifically points towards an air leak, not a general malfunction.

2. What is the purpose of an escharotomy in burn management?

A. To relieve pressure and improve circulation in burn injuries
B. To remove necrotic tissue from a wound
C. To prevent infection in burn injuries
D. To remove excess fluid from burn wounds

Correct answer: A

Rationale: An escharotomy is performed to relieve pressure in areas affected by deep burns and improve circulation. This procedure involves making incisions through the eschar (burned and dead tissue) to release constricting tissue and allow for the return of blood flow. Choice B is incorrect because the removal of necrotic tissue is typically done through debridement, not escharotomy. Choice C is incorrect because preventing infection in burn injuries is usually achieved through proper wound care and antibiotic therapy, not escharotomy. Choice D is incorrect because removing excess fluid from burn wounds is managed through methods like fluid resuscitation and monitoring, not escharotomy.

3. A nurse in an emergency department is caring for a client who has sustained multiple injuries. The nurse observes the client's thorax moving inward during inspiration and outward during expiration. The nurse should suspect which of the following injuries?

A. Flail chest
B. Hemothorax
C. Pulmonary contusion
D. Pneumothorax

Correct answer: A

Rationale: The correct answer is A: Flail chest. Flail chest results from multiple rib fractures, causing paradoxical chest movement where the injured part moves inward during inspiration and outward during expiration, interfering with ventilation. Choice B, Hemothorax, involves blood in the pleural cavity and does not typically cause paradoxical chest movement. Choice C, Pulmonary contusion, is a bruise to the lung tissue and does not present with paradoxical chest movement. Choice D, Pneumothorax, is the presence of air in the pleural space, leading to lung collapse, but it does not demonstrate paradoxical chest movement like in flail chest.

4. What is the priority action for a patient with chest pain from acute coronary syndrome?

A. Administer sublingual nitroglycerin
B. Check the patient's cardiac enzymes
C. Administer aspirin
D. Obtain IV access

Correct answer: A

Rationale: The correct answer is to administer sublingual nitroglycerin. This medication helps dilate the blood vessels, reducing the workload of the heart and improving blood flow to the heart muscle, which is crucial in the management of acute coronary syndrome. Checking cardiac enzymes (choice B) is important for diagnosing a heart attack but is not the priority over providing immediate relief to the patient's chest pain. Administering aspirin (choice C) is also important in acute coronary syndrome to prevent further clot formation, but it is not the priority action for immediate pain relief. Obtaining IV access (choice D) is necessary for administering medications or fluids; however, in this scenario, providing sublingual nitroglycerin for prompt pain relief takes precedence.

5. What should be monitored for in a patient with compartment syndrome?

A. Unrelieved pain, pallor, and pulselessness
B. Localized redness and swelling
C. Fever and infection
D. Muscle weakness and fatigue

Correct answer: A

Rationale: Correct Answer: A. Unrelieved pain, pallor, and pulselessness are classic signs of compartment syndrome that indicate inadequate blood flow to the affected area. These symptoms are crucial to monitor as they signify a medical emergency requiring immediate intervention. Choices B, C, and D are incorrect because they do not align with the typical manifestations of compartment syndrome. Localized redness and swelling may be present but are not the primary indicators. Fever and infection are also not specific to compartment syndrome, and muscle weakness and fatigue are not typically prominent symptoms of this condition.