Med Surge HESI Exam Questions and Answers | 100% Correct/Verified With Rationales | Graded A+ | Latest Update 2024/2025.

A nurse is assessing a client who has a closed chest tube drainage system. The nurse notes constant bubbling in the water seal chamber. What actions should the nurse take? (Select all that apply). Clamping the chest tube Changing the drainage system Assessing the system for an external air leak Reducing the degree of suction being applied Documenting assessment findings, actions taken, and client response Rationale: Constant bubbling in the water seal chamber of a closed chest tube drainage system may indicate the presence of an air leak. The nurse would assess the chest tube system for the presence of an external air leak if constant bubbling were noted in this chamber. If an external air leak is not present and the air leak is a new occurrence, the physician is notified immediately, because an air leak may be present in the pleural space. Leakage and trapping of air in the pleural space can result in a tension pneumothorax. Clamping the chest tube is incorrect. Additionally, a chest tube is not clamped unless this has been specifically prescribed in the agency’s policies and procedures. Changing the drainage system will not alleviate the problem. Reducing the degree of suction being applied will not affect the bubbling in the water seal chamber and could be harmful. The nurse would document the assessment findings and interventions taken in the client’s medical record. Test-Taking Strategy: Use the process of elimination and your knowledge regarding the priority actions in the care of a closed chest tube drainage system. Focus on the data in the question, noting that there is bubbling in the water seal chamber. Recalling that this may indicate an air leak will direct you to the correct options. Review the nursing actions to be taken immediately in the event that complications of a closed chest tube drainage system occur if you had difficulty with this question. A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody secretions. The nurse would first: Continue suctioning to remove the blood Check the degree of suction being applied Encourage the client to cough out the bloody secretions Remove the suction catheter from the client’s nose and begin vigorous suctioning through the mouth Rationale: The return of bloody secretions is an unexpected outcome of suctioning. If it occurs, the nurse should first assess the client and then determine the degree of suction being applied. The degree of suction pressure may need to be decreased. The nurse must also remember to apply intermittent suction and perform catheter rotation during suctioning. Continuing the suctioning or performing vigorous suctioning through the mouth will result in increased trauma and therefore increased bleeding. Suctioning is normally performed on clients who are unable to expectorate secretions. It is therefore unlikely that the client will be able to cough out the bloody secretions. Test-Taking Strategy: Use the process of elimination. Eliminate the options of continuing the suctioning to remove the blood and removing the suction catheter from the nose to begin vigorous suctioning through the mouth, because they are comparable or alike. Next eliminate the option that involves encouraging the client to cough out the bloody secretions, because it is unlikely that the client will be able to do so. Review the nursing actions to be taken immediately in the event of a complication during suctioning if you had difficulty with this question. A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction catheter from the client’s trachea but is unable to do so. The nurse would first: Call a code Contact the physician Administer a bronchodilator Disconnect the suction source from the catheter Rationale: Inability to remove a suction catheter is a critical situation. This finding, along with the client’s symptoms presented in the question, indicates the presence of bronchospasm and bronchoconstriction. The nurse immediately disconnects the suction source from the catheter but leave the catheter in the trachea. The nurse then connects the oxygen source to the catheter. The physician is notified and will most likely prescribe an inhaled bronchodilator. The nurse also prepares for emergency resuscitation if the bronchospasm is not relieved. Test-Taking Strategy: Use the process of elimination, noting the strategic word “first.” Eliminate the option of administering a bronchodilator, because this action requires a physician’s prescription. To select from the remaining options, visualize the situation presented in the question. Noting that the nurse is unable to remove the suction catheter from the client’s trachea will direct you to the correct option. Review the nursing actions to be taken immediately in the event of a complication during suctioning if you had difficulty with this question. A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. The nurse first: Contacts the physician Checks for kinks in the drainage system Checks the client’s blood pressure and heart rate Connects a new drainage system to the client’s chest tube Rationale: If a chest tube is not draining, the nurse must first check for a kink or clot in the chest drainage system. The nurse also observes the client for signs of respiratory distress or mediastinal shift; and if such signs are noted, the physician is notified. Checking the heart rate and blood pressure is not directly related to the lack of chest tube drainage. Connecting a new drainage system to the client’s chest tube is done once the fluid drainage chamber is full. A specific procedure is followed when a new drainage system is connected to a client’s chest