Chest Tubes – Flashcards
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A pt is diagnosed with a tension pneumothorax resulting from the chest hitting the steering wheel in an automobile accident. The emergency department nurse knows that highest priority is given to which?
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Chest tube insertion
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The nurse identifies which group of equipment is essential to have at the bedside of a pt with a closed-chest chest tube drainage system in place?
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Sterile connector, sterile petrolatum gauze pad, padded clamp
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An adult is in a motorcycle accident and sustains three fractured ribs and a pneumothorax. A chest tube is inserted. The nurse should take which of the following actions?
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Monitor the fluctuation in the tube
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A pt with a chest tube asks the nurse about the bubbling he sees in the water seal chamber of his drainage equipment. Which response by the nurse is MOST appropriate?
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It shows your lung has not yet re-expanded"
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The nurse cares for a pt after a CABG. Which observations during the postoperative period MOST concerns to the nurse?
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The heavy chest tube drainage suddenly stops
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The chest tubes must have water seal chamber with sterile water with this amount ----?
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2 cm
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The fill suction control chamber of chest tube with sterile water with this amount ____?
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20 cm
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The system of the chest tube system should be below/above the level of insertion?
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below level of insertion, clamp for only a second to check for leaks
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when removing chest tube have pt. do this before removal?
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valsalva maneuver and clamp chest tube, remove quickly, apply occlusive dressing
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The nurse assesses a patient who has a chest tube and a three-chamber water-seal drainage system (Pleur-evac) connected to suction. Which occurrence would require an intervention by the nurse?
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continuous bubbling in the WATER SEAL CHAMBER Indicates leak
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What is an expected finding in a Pleur-evac?
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Continuous bubbling in the SUCTION CONTROL CHAMBER. The fluid in the chest tube fluctuates with the patient's respirations
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Chest Tube, tubing interventions to AVOID:
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1. Should be coiled on the bed NOT FLOOR 2. No dependent loops. 3. Avoid kinks 4. Do NOT milk clots from line.
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A client had a thoracotomy three hours ago. For the past two hours, there has been 100 ml/hour of bloody chest drainage. Which of the following actions should the nurse take FIRST? 1. Increase the IV fluid rate. 2. Administer oxygen at 5 L/minute per oxygen mask. 3. Elevate the head of the bed. 4. Advise the physician of the amount of drainage.
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4. Advise the physician of the amount of drainage. (chest drainage of 100 ml/hour is abnormal; physician should be notified)
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The first part of the 3 chambers of Pleuro-Vac?
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Look from RIGHT to LEFT 1. Drainage Chamber 2. Water Seal Chamber 3. Suction Chamber
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Placement of CT: air ?
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anterior, superior
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Placement of CT: fluid ?
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posterior, inferior
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Tube placement for Pneumo/Tension Pneumo.?
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2nd ICS, midclavicular
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Tube placement for pleural effusion?
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5th/6th ICS, posterior
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Chest tube drainage
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• first 24 hours: 500 ml-1,000 ml bloody drainage is normal • 100-300 ml may accumulate during the first 2 hours then drainage should be lesser in amount • DRAINAGE MORE THAN 100 ml/hour is excessive and may indicate bleeding MD SHOULD BE NOTIFIED • NOTIFY MD IF CLIENT c/o CHEST PAIN/TIGHTNESS • CLAMPING IS NOT ALLOWED EXCEPT WHEN..... CHANGING UNIT OR.... WHEN THE CHEST TUBE IS ACCIDENTALLY DISCONNECTED FROM THE CLIENT'S CHEST, COVER THE CHEST TUBE SITE WITH PETROLEUM GAUZE •tube is ready to come out with complete re-expansion of the lungs confirmed by CXR and an OUTPUT OF LESS THAN 100 ML IN 24 HOURS
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The nurse reviews the record for a patient with a chest tube attached to a Pleur-evac system. The nurse evaluates which of the following nursing actions is appropriate? 1. "Chest tube was clamped." 2. "Pleur-evac next to bed." 3. "Suction decreased to 15 cm." 4. "Chest tube disconnected from the Pleur-evac."
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2. "Pleur-evac next to bed." Pleur-evac should be maintained below the level of the chest to prevent back flow of fluid and air into the pleural space 3: there is no reason to decrease the level of suction
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A client had a thoracotomy three hours ago. For the past two hours, there has been 100 ml/hour of bloody chest drainage. Which of the following actions should the nurse take FIRST? 1. Increase the IV fluid rate. 2. Administer oxygen at 5 L/minute per oxygen mask. 3. Elevate the head of the bed. 4. Advise the physician of the amount of drainage.
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4. Advise the physician of the amount of drainage. (chest drainage of 100 ml/hour is abnormal; physician should be notified)
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Water Seal Chamber
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The water seal chamber acts as a ONE-WAY valve (air goes out, none goes in). Monitor for continuous bubbling in the water seal chamber. Continuous bubbling in the water seal is abnormal and indicates an air leak. "Intermittent bubbling" in water seal chamber with forced expiration or cough is OK. If the nurse notes that there is CONTINUOUS bubbling in the water seal chamber, check for leaks in the system. With physician's order, RN places padded clamp closest to dressing. If leak stops, air leak is at insertion site. If bubbling continues, leak is between clamp and drainage system. Water should RISE ; FALL in water seal with respirations. If there is no fluctuations: 1. Tube is kinked 2. Pt laying on tube 3. Fluid in the tube 4. Lung fully expanded (blocking the tube
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Suction Chamber
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WHILE SUCTION IS APPLIED, it is NORMAL to have GENTLE BUBBLING. Suction—can be applied to enhance pressure differences. Very low wall suction: 20 cm of water There will be gentle bubbling (should not be vigorous bubbling).
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Drainage Collection Chamber
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Do not empty the contents. Monitor CT drainage q 15 minutes for at least 4 hours then at hourly intervals, for the first 24 hours, depending on the amount of drainage. Record hourly drainage. Mark level of drainage with marker on drainage collection chamber. Should NOT be ;100 ml/hr. ;100 ml/hr—is excessive—notify physician. After first 24 hours, assess drainage every 8 hours.
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client undergoes peritoneal dialysis at home. The home care nurse notices the fluid outflow is inadequate. Which of the following actions should the nurse take FIRST? 1. Turn the client from side to side. 2. Check for kinks in the tubing. 3. Close the clamp to the drainage tubing for one half hour, and then reopen. 4. Milk the drainage tubing firmly every 20 minutes.
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1. Turn the client from side to side. Checking for kinks in the tubing- 2nd action
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Four days after a client has an abdominal perineal resection, which of the following signs is MOST important for the nurse to report to the physician? 1. Moderate amount of serosanguineous drainage on the abdominal dressing. 2. Nausea, vomiting, and increased abdominal distention. 3. Moderate amount of yellow-green nasogastric drainage and decreased urine output. 4. Urinary output via Foley catheter 120 ml over a 4-hour period.
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. Nausea, vomiting, and increased abdominal distention. (symptoms indicate paralytic ileus and should be reported to the physician) 3: nasogastric drainage is expected after this type of surgery, but amount of urinary output is not expected to change significantly
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A 5-year-old child is returned to the pediatric intensive care unit after cardiac surgery. The child has a left chest tube attached to water-seal drainage, an intravenous line running of D5½NS at 4 mL/hr, and a double-lumen nasogastric tube connected to continuous suction. A cardiac monitor is in place, as is a dressing on the left side of the chest dressing. What is the priority nursing intervention? 1Auscultating breath sounds 2Testing the level of consciousness 3Measuring drainage from both tubes 4Determining the suction pressure of the nasogastric tube
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1Auscultating breath sounds
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An infant who underwent open repair of a fractured sternum now has a chest tube. What should the nurse explain to the parents concerning the chest tube? The infant will not feel any discomfort. It is inserted to drain the chest cavity of air. The tube has been inserted in case of an emergency. It will be removed when the infant tolerates feedings.
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It is inserted to drain the chest cavity of air.
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A client is admitted to the postanesthesia care unit after a segmental resection of the right lower lobe of the lung. A chest tube drainage system is in place. When caring for this tube, what should the nurse do? Raise the drainage system to bed level and check its patency. Clamp the tube when moving the client from the bed to a chair. Mark the time and fluid level on the side of the drainage chamber. Secure the chest catheter to the wound dressing with a sterile safety pin
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Mark the time and fluid level on the side of the drainage chamber
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A client has a chest tube for a pneumothorax. The nurse finds the client in respiratory difficulty, with the chest tube separated from the drainage system. What should the nurse do? Obtain a new sterile drainage system. Use two clamps to close the drainage tube. Place the client in the high-Fowler position. Reconnect the client's tube to the drainage system.
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Reconnect the client's tube to the drainage system.
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The parents of a child who is scheduled for open-heart surgery ask why their child must be subjected to chest tubes after surgery. What should the nurse consider before responding in language that the parents will understand?
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They will increase tidal volume. Drainage of air and fluid will be facilitated. They will maintain positive intrapleural pressure. Pressure on the pericardium and chest wall will be regulated
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30. An unlicensed assistive personnel (UAP) is taking care of a patient with a chest tube. The nurse should intervene when she observes the UAP a. looping the drainage tubing on the bed. b. securing the drainage container in an upright position. c. stripping or milking the chest tube to promote drainage. d. reminding the patient to cough and deep breathe every 2 hours
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30. c. If chest tubes are to be milked or stripped, this procedure should be done only by the professional nurse. This procedure is no longer recommended, as it may dangerously increase pleural pressure, but there is no indication to milk the tubes when there is no bloody drainage, as in a pneumothorax. The UAP can loop the chest tubing on the bed to promote drainage and patients should be reminded to cough and deep breathe at least every 2 hours to aid in lung reexpansion. Securing the drainage container in an upright position is also a necessary activity that can be completed by UAP.
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19. An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next? a. Milk the chest tube gently to remove any clots. b. Clamp the chest tube momentarily to check for the origin of the air leak. c. Assist the patient to deep breathe, cough, and use the incentive spirometer. d. Set up the patient controlled analgesia (PCA) and administer the loading dose of morphine.
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ANS: D The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy and would not require milking of the chest tube. An air leak is expected in the initial postoperative period after thoracotomy.
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21. The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed? a. A large air leak in the water-seal chamber b. 400 mL of blood in the collection chamber c. Complaint of pain with each deep inspiration d. Subcutaneous emphysema at the insertion site
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ANS: B airway-breathing-circulation (abc). The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. An air leak would be expected immediately after chest tube placement for a pneumothorax. Initially, brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax. A small amount of subcutaneous air is harmless and will be reabsorbed
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One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing interventions? Water-seal chamber has 5 cm of water. No new drainage in collection chamber Chest tube with a loose-fitting dressing Small pneumothorax at CT insertion site
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C If the dressing at the CT insertion site is loose, an air leak will occur and will need to be sealed. The water-seal chamber usually has 2 cm of water, but having more water will not contribute to an air leak, and it should not be drained from the CDS. No new drainage does not indicate an air leak but may indicate the CT is no longer needed. If there is a pneumothorax, the chest tube should remove the air.
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In caring for the postoperative patient on the clinical unit after transfer from the PACU, which care can be delegated to the unlicensed assistive personnel (UAP)? Monitor the patient's pain. Do the admission vital signs. Assist the patient to take deep breaths and cough. Change the dressing when there is excess drainage.
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C The UAP can encourage and assist the patient to do deep breathing and coughing exercises and report complaints of pain to the nurse caring for the patient. The RN should do the admission vital signs for the patient transferring to the clinical unit from the PACU. The LPN or RN will monitor and treat the patient's pain and change the dressings.
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19. A client is 3 hours postoperative following a right upper lobectomy. The collection chamber of the closed pleural drainage system contains 400 ml of bloody drainage. The client's vital signs are blood pressure 100/50 mmHg, heart rate of 100 beats per minute, and respiratory rate 26 breaths per minute. There is intermittent bubbling in the water seal chamber. One hour following the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant and the client appears dyspneic. The nurse should first check: a) lung sounds b) vital signs c) the chest tube connections d) the amount of drainage
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PRIORITIZATION 19) C - Constant bubbling in the water seal chamber indicates an air leak. This is most likely related to an air leak caused by a loose connection. Other causes might be a tear or incision in the pulmonary pleura, which requires physician intervention. Although the items in options A, B, and D need to be assessed, they should be performed after initial attempts to locate and correct the air leak.
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What is an expected finding in a Pleur-evac?
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Continuous bubbling in the suction control chamber The fluid in the chest tube fluctuates with the patient's respirations
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Patient after thoracotomy with pleur evac drainage system in place. What observation most concerns the nurse?
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The level of the fluid in the water seal chamber remains stable. (water seal chamber should fluctuate with respirations of the patient, rising with inspiration and falling expiration)
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What does absence of fluctuation in a pleur evac drainage system indicate
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lung has re-expanded ( which is desired) or that there is an obstruction of the chest drainage tubes (Not desired)
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What is the most common cause of tubing obstruction of a pleur evac drainage system
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patient lying on the tubing ( Other causes kinking, dependent loops, clots, fibrin)
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A stable patient, hospitalized with a chest tube is scheduled for a chest x-ray. Who can the Charge Nurse delegate the task of transporting this patient to radiology for their x-ray? SELECT ALL THAT APPLY 1. Transport Tech 2. RN 3. LPN 4. Radiology Tech 5. UAP
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2. 3. RN and LPN Then patient is stable but requires monitoring of the Closed Chest Drainage System so a Nurse must be the one doing that
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The male client who has right-sided tubes asks the UAP to help him go to the bathroom, Which situation warrants immediate intervention from the nurse? 1. the uap keeps the chest tube below the level of the chest 2. the uap removes the pleuravic from the wall suction 3. the uap stands to the side and behind the client when the client is ambulating 4. the uap clamps the chest tube closet to the client's chest
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CORRECT : ANSWER 4: The chest tubes should never be clamped because it may lead to tension pneumothorax. ambulating the client safely facilitates lung ventilation. drainage systems are portable and should be kept lower than the chest to promote drainage and prevent reflux. the chest tube system can function due to gravity, it does not have to be attached to suction.
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The client has a right sided chest tube. as the client is getting out of the bed, the tube is accidently pulled out of the pleural space. which action should the nurse implement first? 1. notify the hcp 2. request a new chest tube 3. place a vaseline gauze over the insertion site 4. tell the client to exhale forcefully
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Correct answer: 4 the client should FIRST exhale forcefully to push air out of the pleural space SECOND nurse can apply a vaseline gauze, request a new chest tube THIRD notifify the HCP
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When is it beneficial to clamp a patient's chest tube? A. When ordered by a physician to simulate tube removal and assess the patient's response B. Whenever a patient leaves the nursing unit and cannot be monitored C. When ambulating a postoperative patient with a chest tube D. It is never beneficial to clamp a patient's chest tube
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A. when ordered by a physican to stimulate tube removal and asses the patient's response
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22. A client who experiences repeated pleural effusions from inoperable lung cancer is to undergo pleurodesis. The nurse plans to assist with which of the following after the physician injects the sclerosing agent through the chest tube? a) ambulate the client b) clamp the chest tube c) ask the client to cough and deep breathe d) ask the client to remain in one position only
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22) B - After injection of the sclerosing agent, the chest tube is clamped to prevent the agent from draining back out of the pleural space. A repositioning schedule is used by some physicians, but its usefulness in dispersing the substance is controversial. Ambulation, coughing, and deep breathing have no specific purpose in the immediate period after injection
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25. A nurse is planning care for a client with a chest tube attached to a Pleur-Evac drainage system. The nurse avoids which of the following activities to prevent a tension pneumothorax? a) clamping the chest tube b) adding water to the suction control chamber as it evaporates c) maintaining the collection chamber below the client's waist d) tapping the connection between the chest tube and the drainage system
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25) A - To prevent a tension pneumothorax, the nurse avoids clamping the chest tube, unless specifically ordered. In many facilities, clamping of the chest tube is contraindicated by agency policy. Adding water to the suction control chamber is an appropriate nursing action and is done as needed to maintain the full suction level ordered. Taping the connection between the chest tube and system is also indicated to prevent accidental disconnection. Maintaining the system below waist level is indicated to prevent fluid from reentering the pleural space.
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Rank in order the steps when assisting a client with a chest tube to ambulate? 4. upon return to bed, position the drainage tubes and containers appropriately 2. keep drainage container below level of body cavity being drained 3. nurses or client can hold drainage container during ambulation 1. Assist the client out of bed as described
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1. Assist the client out of bed as described 2. keep drainage container below level of body cavity being drained 3. nurses or client can hold drainage container during ambulation 4. upon return to bed, position the drainage tubes and containers appropriately
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Lou, a nursing student is developing a plan of care for a client with a chest tube that is attached to a Pleur-Evac drainage system. The nurse intervenes if the student writes which incorrect intervention in the plan? a. Position the client in semi-Fowler's position b. Add water to the suction chamber as it evaporates c. Tape the connection sites between the chest tube and the drainage system d. Instruct the client to avoid coughing and deep breathing
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10. D. It is important to encourage the client to cough and deep breathe when a chest tube drainage system is in place. This will assist in facilitating appropriate lung re-expansion. Water is added to the suction chamber as it evaporates to maintain the full suction level prescribed. Connections between the chest tube and the drainage system are taped to prevent accidental disconnection. The client is positioned in semi-Fowler's to facilitate ease in breathing.
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What is a chest tube inserted in to the pleural space used for? 1. allow drainage of fluid and air and to reestablish negative pressure 2. deep breathing and coughing will becoe easier once fluid and hair have been removed from teh pleural space and negative pressure has been reestablished 3. lungs will expand as the fluid and air are removed from the pleural space 4. chest tubes have no impact on internal hemorrhage. however, a rising fluid level in the collection chamber, a drop in blood pressure, and a rapid pulse are indicators of hemmorage
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1. allow drainage of fluid and air and to reestablish negative pressure
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If there is an air leak withitn the drainage system, the nurse would observe a _______ bubbling in the water-seal . This must be corrected by locating the source of the leak and repairing it. 1. continuous 2. intermittent 3. floatation
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1 . continuous
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The only way to reexpand the lungs is to _______on the right side so the air in the pleural space can be removed and the lung reexpanded? 1. chest tube 2. antibiotic 3. bronchodilators 4. hyperbaric chamber
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1. chest tube. right side so the air in the pleural space can be removed and the lung reexpanded. Antibiotics and bronchodilators would have no effect on teh lung reexpansion, nor would the hyperbaric chamber
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A patient with a tramatic injury, has a hemothorax, in which blood collection causes the collapse of the lung. there is a very slight chance of nickign an intercostal artery durign insertion, but its fairly unlikey if the person ______ has been trained. The intial chest xray would help confirm whether there was blood in teh pleural space or just air. What will be a nursing intervention?
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chest tube placement to drain the blood from the space and reexpand the lung
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Is it expected client with chest tube insertions post op to have for normal Broncho vesicular breath sounds in that area?
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Yes, it is NORMAL and EXPECTED and the client's oxygenation status will improve. A chest xray should be done to ensure reexpansion. all other sounds are ABNORMAL
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what are indications of chest reexpansion post op? Iselect all that apply) 1. Fluctuation in water chamber 2. tachycardia, hypotension, bleeding at site 2. schedule client to remove chest tube 4. pneumothorax and dyspnea
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correct answer: 1, 3, One indication of reexpansion is the cessation of flutuation in the water seal chamber when suction isnt applied. drainage should be minimal before the chest tube is removed. All ABC analysis may be done to ensure proper oxygenation but not ncessary. if clinical assessment criteria are met. the chest tube isnt removed until its determined the clients lung has adequately reexanded and will stay that way. after the lung stays expanded, the chest tube is removed.
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a client needs to have a chest tube inserted in the right upper chest. which action is part of the nurse's role? 1. the nurse isnt needed 2. preparing the chest tube drainage system 3. bringing the xray to the clients room 4. inserting the chest tube
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2. the nurse must anticipate that a drainage system is required and assemble it before the insertion so that the tube can directly connected to the drainage system. the chest xray doesnt need to be brought to the client's room. a physcian will insert the chest tube.
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If a patient has absence of breathe sounds with a chest tube?
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NOTIFY HCP IMMEDIATLY
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2. Nurse Kim is caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is appropriate? a. Do nothing, because this is an expected finding. b. Immediately clamp the chest tube and notify the physician. c. Check for an air leak because the bubbling should be intermittent. d. Increase the suction pressure so that bubbling becomes vigorous
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Answer A. Continuous gentle bubbling should be noted in the suction control chamber. Option B is incorrect. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy). Option C is incorrect. Bubbling should be continuous and not intermittent. Option D is incorrect because bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system.
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(SELECT ALL THAT APPLY) After having a lobectomy for lung cancer, a client receives a chest tube connected to a three-chamber chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes which of the following?
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(1) Fluctuations in the water-seal chamber occur when the client breathes. (3) Intermittent bubbling occurs in the water-seal chamber. (4) Gentle bubbling occurs in the suction control chamber. (5) Drainage is collecting in the drainage chamber
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A client is unable to take a deep breath effectively and doesn't want to get out of bed because his chest tube is causing discomfort. To increase client compliance with ambulation and deep breathing, the nurse should:
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1. administer pain medication BEFORE having the client deep-breathe, cough, or get out of bed.
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The nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess a client for pneumothorax resolution after the procedure, the nurse can anticipate that he'll require:
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4. a chest X-ray.
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The physician inserts a chest tube into a client to treat a pneumothorax. The tube is connected to water-seal drainage. The nurse can prevent chest tube air leaks by:
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3. checking and taping all connections.
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5 nursing interventions after chest tube insertion
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maintain a dry occlusive dressing on the chest tube, keep all tubing connections tight and taped, monitor the patients clinical status, encourage the patient to breathe deeply periodically, monitor the fluid drainage and mark the time of measurement and the fluid level
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What IMMEDIATE action should the nurse take when a chest tube becomes disconnected from a bottle or suction apparatus?
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place the end of the tube in STERILE WATER at a 2cm level, apply an occlusive dressing and notify health care provider stat (ASEPIS TECHNIQUE)
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Twelve hours after chest tube insertion for hemothorax, the nurse notes that the client's drainage has decreased from 50 ml/hr to 5 ml/hr. What is the best inital action for the nurse to take? A. Document this expected decrease in drainage. B. Clamp the chest tube while assessing for air leaks. C. Milk the tube to remove any excessive blood clot build up. D. Assess for kinks or dependent loops in the tubing.
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D. The least invasive action should be performed to assess the decrease in drainage. (A) is completed after assessing for and problems causing the decreased drainage. (B) is no longer protocol because the increased pressure may be harmful for the client. (C) is an appropriate nursing action after the tube has been assessed for kinks or dependent loops.
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The nurse is caring for a client with a chest tube to water seal drainage that was inserted 10 days ago because of a ruptured bullae and pneumothorax. Which finding should the nurse report to the healthcare provider before the chest tube is removed? A. Tidal of water in the water seal chamber B. Bilateral muffled breath sounds at bases C. Temperature of 101 degrees F D. Absence of chest tube drainage for 2 days.
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A. Tidal in the water seal chamber should be reported to the HPC to show that the chest tube is working properly. (B) may indicate hypoventilation from the chest tube and usually improves when the tube is removed. (C) indicates infection (D) is an expected finding.
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chest tube
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decreased drainage =assess for kinks or dependant loops -do not clamp off
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The nurse is caring for a client diagnosed with flail chest who has had a chest tube for 3 days. The nurse notes there is no tidaling in the water-seal compartment. Which initial action should be taken by the nurse? 1. Check the tubing for any dependent loops. 2. Auscultate the client's posterior breath sounds. 3. Prepare to remove the client's chest tubes. 4. Notify the HCP that the lungs have re-expanded
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PDA--MAKING NURSING DECISIONS: The nurse should use some tool as a reference to guide in the decision-making process. In this situation, apply Maslow's Hierarchy of Needs. Physiological needs have priority over psychosocial ones. 13. 1. After 3 days, the nurse should suspect that the lung has re-expanded. The nurse should not expect dependent loops to have caused this situation. 2. After 3 days, the nurse should assess the lung sounds to determine whether the lungs have re-expanded. This would be the nurse's first intervention. 3. This will be done if it is determined the lungs have re-expanded, but it is not the first intervention. 4. The nurse should notify the HCP if it is determined the lungs have re-expanded; a chest x-ray can be taken prior to removing the chest tubes. Content - Medical/Surgical: Category of Health Alteration - Respiratory: Integrated Processes - Nursing Process: Implementation: Client Needs - Physiological Integrity: Reduction of Risk Potential:
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The nurse is caring for a client who has a chest tube. What should the nurse do? Prioritize the nurse's actions from first (1) to last (5). 1. Assess the client's lung sounds. 2. Note the amount of suction being used. 3. Check the chest tube dressing for drainage. 4. Make sure that the chest tube is securely taped. 5. Place a bottle of sterile saline at the bedside.
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PDA--- Correct Answer: 1, 4, 3, 2, 5 1. The nurse should begin the care by assessing the client. Remember the nursing process. 4. The nurse should have the client's chest and dressing exposed and should check to make sure the chest tube is securely taped at this time. 3. The nurse then follows the chest tube to the drainage system and assesses the system. 2. The last part of the chest tube drainage system to assess is the suction system. 5. The nurse should make sure that emergency supplies are at the bedside last. Content - Medical/Surgical: Category of Health Alteration - Respiratory :Integrated Processes - Nursing Process: Assessment: Client Needs - Safe and Effective Care Environment: Manag
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The nurse assists with the insertion of a chest tube in a client diagnosed with a spontaneous pneumothorax. Which data indicates that the treatment has been effective? 1. The chest x-ray indicates consolidation. 2. The client has bilateral breath sounds. 3. The suction chamber has vigorous bubbling. 4. The client has crepitus around the insertion site.
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PDA---1. Consolidation indicates fluid or exudates in the lung—pneumonia. This would not indicate the client is improving. 2. Bilateral breath sounds indicate the left lung has re-expanded and the treatment is effective. 3. Vigorous bubbling in the suction chamber indicates that there is a leak in the system, but this does not indicate the treatment is effective. 4. Crepitus (subcutaneous emphysema) indicates that oxygen is escaping into the subcutaneous layer of the skin, but this does not indicate the lung has re-expanded, which is the goal of the treatment. Content - Medical/Surgical: Category of Health Alteration - Respiratory: Integrated Processes - Nursing Process: Assessment: Client Needs - Safe and Effective Care Environment: Safety and Infection Control: Cognitive Level - Analysis
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Ms. Gail is discussing the care of a client with a right-sided chest tube secondary to a pneumothorax with a graduate nurse. Which interventions should Ms. Gail discuss with the graduate nurse? Select all that apply. 1. Place the client in the high-Fowler's position. 2. Assess the chest tube drainage system every shift. 3. Maintain strict bed rest for the client. 4. Ensure the tubing has no dependent loops. 5. Mark the collection chamber for drainage every shift.
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PDA-Keep the client in high-Fowler's position, if tolerated and not contraindicated, to enhance chest
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a client has a chest tube inserted for the treatment of a pneumothorax. while turning in the bed the client dislodges the tube and it is found in the bed. as the RN is directing the health care team, place the actions of the RN in the correct order. All options must be used. 1. assess v/s and await for further medical orders 2. tap the dressing on three sides 3. apply an occulsive dressing over the puncture site 4. direct the LPN to notify the HCP 5. assess the client's respiratory status
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LIPPINCOTT ALTERNATE FORMAT- correct answer: 3, 2, 4, 5, 1 a chest tube is a flexible, hollow tube placed through the chest wall and into the pleural space. the chest tube is able to relieve trapped air and fluid. if a chest tube is dislodged and coes out, the nurse would immediatlely appy an occlusive dressing such as vaseline gause (many times kept in the client's room) the dressing is taped on three sides. the first action always focuses on the cient. the nurse would direct anther LPN to immedialty notify the health care provider. the nurse would assess the respiratory status.the nurse would obtain v/s and await further orders. test taking strategy; analyze to determine what information the question asks for, which priority actions when a chest tube falls out. always look to the care of the client first. if unsure of the order, look for the first actions and the last or least important action. narrowing the middle aciton s alllows for careful ordering. review nursing actions in the care of a chest tube if you have difficulty.
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The nurse is caring for a postop patient who underwent a thoracic lobectomy. the nurse notes that the patient has two chest tubes in place. one is located toward the lower portion of the thorax. and the other is located higher up on the chest wall. when the family asks why the patient has two chest tubes the best response by the nurse is which of the following? A. "two tubes were necessary due to the amount of beeding from the operative site" B. "both tubes were required in order to drain the blood from two different lung areas" C. "The lower tube will drain blood the higher tube is intended to drain air" D. "the primary drainage tube is lower on the thorax, and th eother is for overflow"
answer
NCLEX HIGH DISASTER PREVENTION (C) The nurse should explain that the tube placed lower on the thorax will drain blood while tube placed higher on teh thorax will allow for removal of air.
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The nurse is providing preop teaching for a patient who will undergo thoracic surgery. which of the following teaching points are important to include for this patient? SELECT ALL THAT APPLY A. you may have chest tubes and drainage appratus after surgery B. You will be assisted to turn, cough, deep brezthe frequently after surgery C. you will be in the intensive care unit for at least one week following surgery D. oxygen will be administered to support your breathing if needed
answer
A, B,D A patient undergorng thoracic surgery should be taught preop about tx expectations during the postop period. it is imptortant for the patient to be aware chest tubes will be inserted during surgery and that he or she will be required to turn, cough, and deep breathe frequently followiing surgery. the patient should be aware that supplementatl oxygen may be required following surgery. patients who undergo thoraic surgery are not necessarily admitted to an intensive care unit postop.
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27. which of the following chest xray findings is consistent with left tension pneumothorax? a. flattening of the diaphragm b. shifting of the mediastinum to the right c. presence of gastric air bubble d. increased translucency of the right lung
answer
B. in tension pneumothorax, there is a mediastinal shift to the opposite side of the chest
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28. water seal chest drainage is used to maintain: a. positive chest wall pressure b. negative chest wall pressure c. positive intrathoracic pressure d. negative intrathoracic pressure
answer
D. water seal chest drainage is used to maintain negative intrathoracic pressure
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16. The nurse is caring for a post patient following thoracotomy with left lower lobectomy. the patient has one chest tube. the nurse must ensure that which of the followign supplies are available at the bedside? SELECT ALL THAT APPLY a. sterile gauze b. suture material c. thoracotomy tray d. sterile petrolatum gauze e. sterile gloves.
answer
A, D, E Post op , the nurse should have sterile gauze, petrolatum gauize, and sterile gloves available in the room in case the chest tube should become dislodged or require reinforcement of the dressing
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When is the collection chamber of the Pleuravac marked and is part of the total output for the client?
answer
The pleuravac should be marked at the END OF EVERY SHIFT
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What does looping the tubing on a chest tube prevent and what does address it safe and effective care?
answer
Looping the tubing prevents direct pressure on the chest tube itself and keeps tubing off the floor, addressing both a SAFETY AND INFECTION control issue.
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The charge nurse is making assignments for the surgical unit. Which client should be assigned to the new graduate nurse? 1. The 84-year-old client who has a chest tube that is draining bright red blood. 2. The 38-year-old client who is 1 day postoperative with a temperature of 101.2ºF. 3. The 42-year-old client who has just returned to the unit after a breast biopsy. 4. The 55-year-old client who is complaining of unrelenting abdominal pain.
answer
PDA 1. This client is not stable and requires a more experienced nurse. 2. An elevated temperature indicates a potential complication of surgery; therefore, this client requires a more experienced nurse. 3. Of the four clients, the one who is most stable is the client who has just undergone a breast biopsy; therefore, this client would be the most appropriate to assign to a new graduate nurse. 4. Unrelenting pain requires further assessment; therefore, the client should be assigned to a more experienced nurse.
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. The unlicensed assistive personnel (UAP) accidentally pulled the client's chest tube out while assisting the client to the bedside commode (BSC). Which intervention should the nurse implement first? 1. Securely tape petroleum gauze over the insertion site. 2. Instruct the UAP how to move a client with a chest tube. 3. Assess the client's respirations and lung sounds. 4. Obtain a chest tube and a chest tube insertion tray.
answer
PDA 1. Taping petroleum gauze over the chest tube insertion site will prevent air from entering the pleural space. This is the first intervention. 2. The nurse would expect the client with ARDS to have respiratory signs/symptoms; therefore, this client does not warrant immediate intervention. 3. One of the signs/symptoms of bacterial meningitis is nucal rigidity; therefore, this client does not warrant immediate intervention. 4. The client with Crohn's disease should be asymptomatic, so pain and diarrhea warrant intervention by the nurse. Pain could indicate a complication.
