4335-wk 5- Chest tubes & EKG (EAQ)

Which action would the nurse perform when a client is in ventricular fibrillation (abnormal heart rhythm)?

-initiating CPR -assessing the EKG (while performing interventions) -using a defibrillator (try to convert client back to normal sinus rhythm) -obtaining electrolytes (determines if hyperkalemia led to the dysrhythmia, imbalances need to be corrected) -administering epinephrine (and/or amiodarone, admin when attempting to change the abnormal rhythm)

Which action would the nurse include in the plan of care for a client who had an ischemic stroke caused by atrial fibrillation and has been placed on anticoagulation therapy to prevent further strokes from occurring?

-wearing a medical alert bracelet -initiating bleeding precautions (ex: use an electric razor) -refraining from estrogen therapy (can lead to clot formation) -obtaining routine prothrombin times -notifying providers of anticoagulation

A client who had thoracic surgery is admitted to the post-anesthesia care unit. The nurse notes that a chest tube is in place and is attached to a disposable plastic, water-seal drainage system. To provide appropriate care of the chest tube and drainage unit, which step would the nurse take next?

Ensure the security of the connections from the client to the drainage unit. -The system must remain airtight (closed) to prevent collapse of the lung. *The system is kept closed; a record of drainage is kept by marking the outside of the container or chamber. * It should bubble but not vigorously; vigorous bubbling will not increase the suction but will cause the fluid to evaporate more rapidly * The water level will fluctuate as the client inhales and exhales. *The level will increase with inspiration and decrease with expiration; this is known as tidaling.

The nurse is assessing an electrocardiogram (ECG) rhythm strip. Which component of the tracing will the nurse observe to determine ventricular depolarization?

QRS complex -The QRS complex represents ventricular depolarization.

When teaching a client with atrial fibrillation about a new prescription for warfarin, the nurse will include information about which vitamin?

Vitamin K -Warfarin causes inhibition of vitamin K-dependent clotting factors, and use of vitamin K would affect the therapeutic effect of warfarin

When a client has sinus tachycardia, which potential causes of the dysrhythmia would the nurse consider when assessing the client? Select all that apply. One, some, or all responses may be correct.

anxiety, caffeine, exercise, anemia -Causes of sinus tachycardia include hypovolemia, heart failure, anemia, exercise, use of stimulants (such as caffeine), fever, and sympathetic response to fear or pain (for example, anxiety). * Hypothermia will cause sinus bradycardia. (not dysrhytmia)

what does the P wave represent in an ECG rhythm strip?

atrial DEpolarization -P wave indicated that the sinoatrial node initiated the impulse that depolarized the atrium

When a client's cardiac monitor shows ventricular tachycardia, which action would the nurse take first?

check for a pulse -The treatment of ventricular tachycardia depends on whether the client has a pulse and is symptomatic with the dysrhythmia *cardiac compression would not be initiated if there was a pulse. *admin of oxygen via an Ambu bag would occur only if the client was not breathing *pt wil pulseless ventricular tachycardia may be defibrillated, but the nurse first needs to check for a pulse.

What will neutral pressure in the pleural space cause?

collapse of the lung

Which finding best indicates that the chest tube for a client with a pneumothorax may be discontinued?

full -re-expansion of the lungs seen on chest x-ray -Chest x-ray films reveal the degree to which the lung fills the pleural cavity and also the presence or absence of pneumothorax.

A nurse is caring for a client with a pneumothorax who has a chest tube attached to a closed chest drainage system. If the chest tube and closed chest drainage system are effective, which type of pressure will be reestablished?

negative pressure in the pleural space -Removal of air and fluid from the pleural space reestablishes negative pressure, resulting in lung expansion.

Which action would the nurse take to determine patency of the chest tube and closed chest drainage system in a client after left lower lobectomy?

observe for fluctuations of the fluid in the water seal chamber -Fluctuations of the fluid in the water-seal chamber indicate effective communication between the pleural cavity and the drainage system.

Which action is essential for the nurse to include in the plan of care for a client with atrial fibrillation?

take pulse apically for 1 full minute -Because the pulse with atrial fibrillation is irregularly irregular, there is a difference between apical and radial pulse rate (pulse deficit) and the apical pulse is used for an accurate heart rate.

what does the T wave represent in an ECG rhythm strip?

ventricular REpolarization

What are expected findings of a client who has a closed chest tube drainage system connected to suction?

-75 mL of blood in the chest tube collection chamber (in the early postop period) -A column of water 20 cm high in the suction control chamber and an intact occlusive dressing at the chest tube insertion site

When caring for a client with symptomatic bradycardia caused by heart block, the nurse will anticipate the need to teach the client about which treatment option?

Demand pacemakers -Treatment for symptomatic bradycardia typically includes placement of a temporary or permanent demand pacemaker to prevent heart rate from dropping below a preset rate.

Which would the nurse use to monitor for torsades de pointes in a client with schizophrenia being treated with chlorpromazine?

Electrocardiogram (ECG) -Chlorpromazine is one of four first-generation antipsychotic medications that can cause life-threatening ventricular fibrillation. The nurse will obtain an ECG and serum potassium level before and during treatment. *Weight gain can be a complication of antipsychotics, but is not a fatal complication. *Serum potassium, not sodium, will be monitored in clients taking chlorpromazine. *Orthostatic hypotension can result in clients taking chlorpromazine, but is generally not a fatal complication and is not related to monitoring for torsades de pointes.

When a client has a chest tube placed in the second intercostal space, how will the nurse evaluate for the effectiveness of the chest tube?

Inspect the amount of bubbling in the water-seal chamber. -A chest tube is placed in the second intercostal space to treat pneumothorax. * The chest tube will remove air from the intrapleural space, causing bubbling in the water-seal chamber. *Bubbling in the suction control chamber indicates that suction is turned on. * Only a few milliliters of drainage are expected with a chest tube placed in the second intercostal space; a tube would be placed at the base of the lung to drain fluid from the pleural space. * Clotting in the tubing would not be expected for a chest tube placed at the second intercostal space because there should be only a few milliliters of bloody drainage.

what will atmospheric pressure in the thoracic cavity cause?

collapse of the lung

what does the PR interval represent in an ECG rhythm strip?

depolarization of the sinoatrial node, both atria, and the atrioventricular node -represents the time required for atrial depolarization, as well as impulses, travel through the conduction system and Purkinje fiber network, inclusive of the P wave and PR segment. it is measured from the beginning of the P wave to the end of the PR segment.

When caring for a client after a thoracotomy, which action would the nurse take to keep the chest tube and closed chest drainage system patent?

Position the drainage system below the level of the client's heart. -Positioning the chest drainage system below the level of the heart assists with the movement of drainage out of the pleural space and into the collection chamber. *Because the chest drainage system is a closed system, the collection chamber is not drained. * If the collection chamber is full before the chest tube is removed, the whole drainage system is replaced. * A chest x-ray is done to check initial chest tube position, but the position does not have to be rechecked every day. *Clients with chest tubes should get up, ambulate in place, and sit at the bedside to avoid the many complications of prolonged bed rest

Which nursing action is of highest priority when a client's chest tube has accident ally dislodged?

apply petroleum gauze dressing over the site -A petroleum gauze dressing will prevent air from being sucked into the pleural space, causing a pneumothorax. The petroleum gauze dressing should be taped only on three sides to allow for excessive air to escape, preventing a tension pneumothorax. The health care provider should be notified immediately and the client assessed for signs of respiratory distress. *Preparing to insert a new chest tube is not a priority of the nurse at this moment.

The client has a closed chest tube drainage system connected to suction. Which assessment finding requires additional evaluation by the nurse?

constant bubbling in the water seal chamber -Constant bubbling in the water-seal chamber is indicative of an air leak. The nurse would assess the entire length of the system from the container to the client's chest wall tube insertion site to find the source of the air leak. If the source of the air leak is not found in the system and bubbling continues, the leak is most likely within the client's chest or at the insertion site. This could cause the lung to collapse because of a buildup of air pressure within the pleural cavity, and the health care provider should be notified.

Which finding in a client who has had a chest tube removed would be of most concern to the nurse?

crepitus at the chest tube site crepitus=Crackling or grating sound caused by bones rubbing against each other, also called creaky joints) -Crepitus at the chest tube site may indicate ongoing pneumothorax and the nurse would take actions such as listening to breath sounds, checking oxygen saturation, checking results of the postremoval chest x-ray, and notifying the health care provider.

When the nurse in the coronary care unit (CCU) identifies ventricular fibrillation on a client's cardiac monitor, which intervention is the priority?

defibrillate the client -When ventricular fibrillation is verified, the first intervention is defibrillation; it is the only measure that will terminate this lethal dysrhythmia. Research indicates that early defibrillation is the strongest indicator for successful resuscitation. *The Code 99 or Rapid Response Team will be notified, but the nurse will not wait to notify the team before attempting defibrillation. *Epinephrine may be administered if defibrillation is initially unsuccessful, but is not the first action. *Cardiopulmonary resuscitation will be started if a defibrillator is unavailable or if initial defibrillation is unsuccessful at ending the ventricular fibrillation.

Which action would the nurse take to prevent complications when caring for a client with a chest tube to water seal drainage system for a pneumothorax?

marking the time on the drainage unit every shift -The nurse would mark the drainage system every shift to determine the amount of drainage. *The drainage system is a closed system, so the nurse would switch out the drainage system when it is full. *Emptying the system would break sterility. *The drainage system should remain below chest level to prevent fluid from backing up into the lungs. *The nurse would notify the health care provider if drainage is greater than 100 mL/h. *The nurse would keep the drainage system upright.