NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions Questions
Extract:
Question 1 of 5
A client has a right-sided chest tube with 50 cc of serosanguinous fluid in the collection chamber and air bubbles are collecting in the water seal chamber. What is the most appropriate action for the nurse to take at this time?
Correct Answer: C
Rationale: The water seal of a chest tube acts as a one-way valve. Air bubbles in the water seal indicate a leak between the client and the chamber. The nurse should briefly clamp the tube near the client's chest to locate the source of the leak. Once identified, the nurse should unclamp the tubing and notify the physician immediately.
Choice A is incorrect because air bubbles in the water seal chamber are not a normal finding and indicate a leak.
Choice B is incorrect as stripping the tubing could aggravate the issue and is not the initial appropriate action.
Choice D is incorrect as it does not address the immediate need to locate and address the leak.
Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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