Nursing Elites

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

• A. An air leak
• B. A blocked chest tube
• C. Normal chest tube function
• D. Continuous drainage from the chest tube

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber of a chest tube indicates an air leak in the system. This occurs when air is entering the system through a leak, preventing the lung from fully re-expanding. Choice B, a blocked chest tube, is incorrect as a blocked tube would result in a lack of drainage rather than continuous bubbling. Choice C, normal chest tube function, is incorrect as continuous bubbling signifies an issue. Choice D, continuous drainage from the chest tube, is incorrect as bubbling in the water seal chamber specifically indicates an air leak, not just the presence of drainage.

2. What are the expected signs of increased intracranial pressure (IICP)?

• A. Restlessness, confusion, irritability
• B. Severe headache and confusion
• C. Elevated blood pressure and bradycardia
• D. Bradycardia and altered pupil response

Correct answer: A

Rationale: The correct answer is A: Restlessness, confusion, irritability. These are early signs of increased intracranial pressure (IICP) and require prompt intervention. Restlessness, confusion, and irritability are indicative of the brain's attempt to compensate for the rising pressure. Choice B is incorrect because severe headache alone is not specific to IICP and can be present in various conditions. Choice C is incorrect because elevated blood pressure is not a common sign of IICP; instead, hypertension may be present in the compensatory stage. Choice D is incorrect as bradycardia and altered pupil response are signs of advanced IICP, not early signs. Monitoring and recognizing these early signs are crucial for timely intervention and preventing further complications.

3. What intervention is needed when continuous bubbling is observed in the chest tube water seal chamber?

• A. Tighten the connections of the chest tube system
• B. Clamp the chest tube
• C. Replace the chest tube system
• D. Continue monitoring the chest tube

Correct answer: A

Rationale: When continuous bubbling is observed in the chest tube water seal chamber, the correct intervention is to tighten the connections of the chest tube system. This can help resolve an air leak that is causing the continuous bubbling. Clamping the chest tube or replacing the entire chest tube system are not appropriate interventions in this scenario. Clamping the tube can lead to a dangerous buildup of pressure, while replacing the chest tube system may not be necessary if the issue can be resolved by simply tightening the connections. Continuing to monitor the chest tube without taking corrective action may lead to complications associated with the air leak.

4. A patient with a chest tube has continuous bubbling in the water seal chamber. What does this indicate?

• A. An air leak
• B. A blocked chest tube
• C. Drainage from the site
• D. Blood clot in the chest tube

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber of a chest tube indicates an air leak. This situation requires immediate attention to prevent complications such as lung collapse. A blocked chest tube would typically result in absent or fluctuating bubbling. Drainage from the site would be observed in the collection chamber, not the water seal chamber. A blood clot in the chest tube would lead to cessation of drainage.

5. A client is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?

• A. Lie on your left side.
• B. Lie on your right side.
• C. Increase your fluid intake.
• D. Decrease your fluid intake.

Correct answer: B

Rationale: After a liver biopsy, the nurse should instruct the client to lie on the right side. This position helps apply pressure to the biopsy site, promoting hemostasis and reducing the risk of bleeding. Lying on the left side may not provide adequate pressure to the site. Increasing fluid intake is generally beneficial to prevent dehydration and aid in the recovery process, whereas decreasing fluid intake could lead to dehydration and possible complications. Therefore, the correct instruction is to lie on the right side.

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