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1. A nurse is caring for a patient who has a chest tube
connected to a water-seal drainage system. The nurse
notices that there is continuous bubbling in the water-seal
chamber. What should the nurse do next?
a) Clamp the chest tube and notify the physician.
b) Check the system for air leaks and tape any connections
that are loose.
c) Document the finding and continue to monitor the
patient.
d) Increase the suction pressure to remove the excess air.
*Answer: b) Check the system for air leaks and tape any
connections that are loose.*
Rationale: Continuous bubbling in the water-seal chamber
indicates an air leak in the system, which can compromise
the drainage of fluid and air from the pleural space and
increase the risk of tension pneumothorax. The nurse
should check the system for air leaks and tape any
connections that are loose. Clamping the chest tube can
cause a buildup of pressure in the pleural space and worsen
the patient's condition. Documenting the finding and
continuing to monitor the patient is not enough to address
the problem. Increasing the suction pressure will not stop
the air leak and may cause damage to the lung tissue.
2. A nurse is preparing to administer an intramuscular
injection to a patient who has a history of anaphylaxis. The
nurse has drawn up 0.3 mL of epinephrine 1:1000 in a
syringe. What is the most appropriate site for the injection?
a) Deltoid muscle
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