Author Question: The nurse is assisting the physician with insertion of a chest tube. The nurse notes fluctuation of ... (Read 90 times)

olgavictoria · **on:** Jul 22, 2018

The nurse is assisting the physician with insertion of a chest tube. The nurse notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this observation, the nurse takes which of the following actions?

1. Ensure that suction is turned on.
2. Reinforce the occlusive dressing.
3. Encourage the client to breathe deeply.
4. Document the accurate functioning of the tube.

Question 2

The nurse is preparing to listen to the apical heart rate of a newborn. The nurse performs the procedure and notes that the heart rate is normal if which of the following is noted?

1. A heart rate of 100 beats/min
2. A heart rate of 140 beats/min
3. A heart rate of 180 beats/min
4. A heart rate of 190 beats/min

SAUXC · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

4

Rationale: The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if a dependent loop exists, if the suction is not working properly, or if the lung has reexpanded. There is no need to ask the client to breathe deeply or to reinforce the dressing. The suction should be turned on if prescribed, but there are no data in the question to indicate this physician's prescription.

Answer to Question 2

2

Rationale: The normal heart rate in a newborn is 120 to 160 beats/min. The other options are incorrect.