Advanced Skills Part 2

Which intervention should the nurse implement first for the client diagnosed with a hemothorax who has had a right sided chest tube for 3 days and has no fluctuation (tidaling) in the water compartment? A. Assess the client's bilateral lung sounds B. Obtain an order for a STAT chest x-ray C. Notify the health-care provider as soon as possible D. Document the finding in the client's chart

A. Assess the client's bilateral lung sounds

Which action should the nurse implement for the client with a hemothorax who has a right-sided chest tube with excessive bubbling in the water-seal compartment? A. Check the amount of wall suction being applied B. Assess the tubing for any blood clots C. Milk the tubing proximal to distal D. Encourage the client to cough forcefully

A. Check the amount of wall suction being applied

Which intervention should the nurse implement for a male client who has had a left sided chest tube for 6 hours and who refuses to take deep breaths because of the pain? A. Medicate the client and have the client take deep breaths B. Encourage the client to take shallow breaths to help with the pain C. Explain that deep breaths do not need to be taken at this time D. Tell the client if he doesn't take deep breaths, he could die.

A. Medicate the client and have the client take deep breaths

The nurse is caring for a client with a right sided chest tube secondary to a pneumothorax. Which interventions should the nurse implement when caring for this client? SATA A. Place the client in the low-fowlers position B. Assess the chest tube drainage system frequently C. Maintain strict bedrest for the client D. Secure a loop of drainage tubing to the sheet E. Observe the site for subcutaneous emphysema

B. Assess the chest tube drainage system frequently D. Secure a loop of drainage tubing to the sheet E. Observe the site for subcutaneous emphysema

The nurse is caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate? A. Do nothing because it is an expected finding B. Check for an air leak because the bubbling should be intermittent C. Increase the suction pressure so that the bubbling becomes vigorous D. Clamp the chest tube and notify the healthcare provider immediately.

B. Check for an air leak because the bubbling should be intermittent

While changing the tapes on a newly inserted tracheostomy tube, the client coughs and the tube is dislodged. The initial nursing action is to: A. Call the physician to reinsert the tube. B. Grasp the retention sutures to spread the opening. C. Call the respiratory therapy department to reinsert the tracheotomy. D. Cover the tracheostomy site with a sterile dressing to prevent infection.

B. Grasp the retention sutures to spread the opening.

Which assessment data indicate to the nurse the chest tubes inserted 3 days ago have been effective in treating the client with hemothorax? A. Gentle bubbling in the suction compartment B. No fluctuation (tidaling) in the water-seal chamber C. The drainage compartment has 250mL of blood D. The client is able to deep breath without any pain

B. No fluctuation (tidaling) in the water-seal chamber

The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial action should the nurse take? A. Call the health care provider B. Place the tube in a bottle of sterile water C. Replace the chest tube system immediately D. Place a sterile dressing over the disconnection site

B. Place the tube in a bottle of sterile water

The client is admitted to the ED with chest trauma. Which s/s indicate to the nurse the diagnosis of pneumothorax? A. Bronchovesicular lung sounds and bradypnea B. Unequal lung expansion and dyspnea C. Frothy, bloody sputum and consolidation D. Barrel chest and polycythemia

B. Unequal lung expansion and dyspnea

The client had a right-sided chest tube inserted 2 hours ago for pneumothorax. Which action should the nurse implement if there is no fluctuation (tidaling) in the water seal compartment? A. Obtain an order for a STAT chest x-ray B. Increase the amount of wall suction C. Check the tubing for kinks or clots D. Monitor the client's pulse oximeter reading

C. Check the tubing for kinks or clots

The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? SATA A. Excessive bubbling in the water seal chamber B. Vigorous bubbling in the suction control chamber C. Drainage system maintained below the clients chest D. 50mL of drainage in the drainage collection chamber E. Occlusive dressing in place over the chest tube insertion site F. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation.

C. Drainage system maintained below the clients chest D. 50mL of drainage in the drainage collection chamber E. Occlusive dressing in place over the chest tube insertion site F. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation.

The nurse is presenting a class on chest tubes. Which statement best describes a tension pneumothorax? A. A tension pneumothorax develops when an air filled bleb on the surface of the lung ruptures B. When a tension pneumothorax occurs, the air moves freely between the pleural space and the atmosphere C. The injury allows air into the pleural space but prevents it from escaping the pleural space D. A tension pneumothorax results from a puncture of the pleura during a central line placement

C. The injury allows air into the pleural space but prevents it from escaping the pleural space

The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action? A. Stay very still B. Exhale very quickly C. Inhale and exhale quickly D. Perform the Valsalva maneuver

D. Perform the Valsalva maneuver