The nurse caring for a patient who has a closed chest drainage ...

[Pineappleeh]

The nurse caring for a patient who has a closed chest drainage system notes that there is fluctuation (tidaling) in the water seal chamber. What is the most appropriate nursing action based on this assessment?
 
  a. Document the tidaling
  b. Elevate the head of the bed and notify charge nurse of malfunction of drainage system
  c. Add more sterile water to the water seal chamber
  d. Turn patient to the affected side

Question 2

The patient has become very dyspneic, respirations are 32, and the pulse is 100. The patient is coughing up frothy red sputum. What should be the initial nursing intervention?
 
  a. Lay the patient flat to reduce hypotension and the symptoms of cardiogenic shock.
  b. Place patient in side-lying position to reduce the symptoms of atrial fibrillation.
  c. Place patient upright with legs in dependent position to reduce the symptoms of pulmonary edema. d.
  Lay the patient flat and elevate the feet to increase venous return in cardiogenic shock.

[Meganchabluk]

Answer to Question 1

ANS: A
Tidaling or fluctuation in the water seal drainage is an indicator that the negative pressure is preserved and the system is working normally. Document this normal finding.

Answer to Question 2

ANS: C
Signs and symptoms of pulmonary edema are restlessness; vague uneasiness; agitation; disorientation; diaphoresis; severe dyspnea; tachypnea; tachycardia; pallor or cyanosis; cough producing large quantities of blood-tinged, frothy sputum; audible wheezing and crackles; and cold extremities. The legs in a dependent position will decrease venous return and ease the pulmonary edema.

[Pineappleeh]

TY

[Meganchabluk]

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