Funds- Care of a Client with a Tube
The nurse is assisting with monitoring the functioning of a chest tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. Which findings should the nurse expect to note? SATA 1. excessive bubbling in the water seal chamber 2. vigorous bubbling in the suction control chamber 3. 50 ml of drainage in the drainage collection chamber 4. the drainage system is maintained below the clients chest 5. an occlusive dressing is in place over the chest tube insertion site 6. fluctuation of water in the tube of the water seal chamber during inhalation and exhalation
3, 4, 5, 6 Rationale: the bubbling of water in the water seal chamber indicates air drainage from the client. this is usually seen when intrathoracic pressure is greater than atmospheric pressure, and it may occur during exhalation, coughing, or sneezing. excessive bubbling in the water seal chamber may indicate an air leak, which is an unexpected finding. the fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. an absence of fluctuation may indicate that the chest tube is obstructed, the lung has re-expanded, or no more air is leaking into the pleural space. gentle bubbling should be noted in the suction control chamber. a total of 50 ml of drainage is not excessive in a client returning to the nursing unit from the recovery room; however, drainage of more than 70 to 100 ml/hr is considered excessive and requires RN and HCP notification. the chest tube insertion site is covered with an occlusive dressing to prevent air from entering the pleural space. positioning the drainage system below the clients chest allows gravity to drain the pleural space
The nurse is assigned to assist with caring for a client with esophageal varices who had a Sengstaken-Blakemore tube inserted because other treatment measures were unsuccessful. The nurse should check the client's room to ensure that which priority item is at the bedside? 1. an obturator 2. a kelly clamp 3. an irrigation set 4. a pair of scissors
4 Rationale: when the client has a sengstaken-blakemore tube, a pair of scissors must be kept at the clients bedside at all times. the client needs to be observed for sudden resp distress, which occurs if the gastric balloon ruptures, and the entire tube moves upward. if this occurs, the RN is notified immediately and the balloon lumens will be cut. an obturator and a kelly clamp are kept at the bedside of a client with a tracheostomy. an irrigation set may also be kept at the bedside, but it is not priority item
The nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. The nurse should provide the client with which information about this type of tube? 1. enables the client to speak 2. prevents the client from speaking 3. is necessary for mechanical ventilation 4. prevents air from being inhaled through the tracheostomy tubing
1 Rationale: a fenestrated tube has a small opening in the outer cannula that allows some air to escape through the larynx, this type of tube enables the client to speak
The nurse is checking a client for the correct placement of a NG tube. The nurse aspirates the client's stomach contents and checks its ph level. Which ph value indicates the correct placement of the tube? 1. 3.5 2. 4.5 3. 6.0 4. 7.35
1 Rationale: if the NG tube is in the stomach, the ph of the contents will be acidic. options 2 and 3 indicate a slightly acidic ph. option 4 is a neutral ph
The nurse is preparing to administer medication through a NG tube that is connected to suction. Which indicates the accurate procedure for medication administration? 1. position the client supine to assist with medication absorption 2. clamp the NG tube for 30 mins after medication administration 3. aspirate the NG tube after medication administration to maintain patency 4. change the suction setting to low intermittent suction for 30 mins after medication administration
2 Rationale: if a client has an NG tube connected to suction, the nurse should wait up to 30 mins before reconnecting the tube to the suction apparatus to allow adequate time for medication absorption. aspirating the NG tube will remove the medication that has just been administered. low intermittent suction will also remove the medication. the client should not be placed in the supine position because of the risk for aspiration
The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. The nurse should take which step next? 1. immediately inflate the balloon 2. insert the catheter 2.5 to 5cm and inflate the balloon 3. insert the catheter until resistance is met and inflate the balloon 4. withdraw the catheter approximately 1 inch and inflate the balloon
2 Rationale: the catheter's balloon is behind the opening at the insertion tip. the catheter is inserted 2.5 to 5cm after urine begins to flow to provide sufficient space to inflate the balloon. inserting the catheter the extra distance will ensure that the balloon is inflated inside the bladder and not in the urethra, which could produce trauma. inserting the catheter until resistance is met could cause trauma to the bladder wall
The nurse is preparing to administer an intermittent tube feeding to a client with a NG tube. The nurse checks the residual and obtains an amount of 200 ml. Which action should the nurse take? 1. hold the feeding 2. administer the feeding 3. flush the tubing with 30ml of water 4. elevate the head of the bed to 90 degrees and administer the feeding
1 Rationale: when 200ml of residual formula are obtained, the feeding is held and the RN is notified because this is an indication that the feeding is not being absorbed. if the residual is less than 100ml, the feeding is usually administered. large volume aspirates indicated delayed gastric emptying and place the client at risk for aspiration. in addition, the nurse should always check the HCP's prescription and agency policy regarding residual amounts. elevating the head of bed to 90 degrees and flushing the tubing are not appropriate actions
The nurse is assigned to assist with caring for a client who has a chest tube. The nurse notes fluctuations of the fluid level in the water seal chamber. Based on this observation, which action would be appropriate? 1. empty the drainage 2. encourage the client to deep breathe 3. continue to monitor, because this is an expected finding 4. encourage the client to hold his or her breath periodically
3 Rationale: the presence of fluctuations in the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. The apparatus and all connections must remain airtight at all times, and the drainage is never emptied because of the risk of disruption in the closed system, which can result in lung collapse. encouraging the client to deep breathe is unrelated to this observation. The client is not told to hold his or her breath
The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which action should the nurse take? 1. notify the rapid response team 2. finish the suctioning as quickly as possible 3. contact the respiratory department to suction the client 4. discontinue suctioning until the client is stabilized and monitor vital signs
4 Rationale: if a client becomes cyanotic or restless or develops tachycardia, bradycardia, or another abdominal heart rhythm, the nurse must discontinue suctioning until the client is stabilized. the nurse would also notify the RN. it is also important to monitor the vital signs and the pulse oximetry. if the client's condition continues to deteriorate, then the resp department and HCP may need to be notified. there is no data in the question that indicates that the rapid response team needs to be notified
The nurse is assigned to care for a client who has a chest tube. The nurse is told to monitor the client for crepitus (subcutaneous emphysema). Which method should be used to monitor the client for crepitus? 1. asking the client about pain 2. checking the resp hourly 3. checking the blood pressure every 2 hours 4. palpating for the leakage of air into the subcutaneous tissues
4 Rationale: subcutaneous emphysema is also known as crepitus. it presents as a puffed up appearance that is caused by the leakage of air into the subcutaneous tissues. it is monitored by palpating , and it feels like bubble wrap when palpated.
The nurse is preparing to begin a continuous tube feeding on a client with a NG tube. In which position should the nurse place the client for safe administration of the tube feeding? 1. supine 2. supine on the right side 3. with the head elevated 15 degrees 4. with the head elevated 45 degrees
4 Rationale: when a tube feeding is administered, the client is placed in a high fowler's position for a bolus feeding and in a semi fowler's position for a continuous feeding to allow gravity to help the flow of formula and to prevent reflux and aspiration.
The nurse is preparing to administer an intermittent feeding to a client. The nurse aspirates 90ml of residual from the tube. What should the nurse do with the aspirated residual? 1. hold the feeding 2. place it into a container for lab analysis 3. reinstill the residual and administer the feeding 4. deduct the amount of the residual from the new feeding and administer that amount to the client
3 Rationale: unless otherwise instructed or if the residual contents appear abnormal, an amount of less than 100 may be reinstituted; then a normal amount of prescribe tube feeding is administered. it is important to return the contents to the stomach to prevent electrolyte imbalances.
The nurse is assisting in planning care for a client with a chest tube. The nurse should suggest to include which interventions in the plan? SATA 1. pin the tubing to the bed linens 2. be sure all connections remain airtight 3. be sure all connections are taped and secure 4. empty the drainage from the drainage collection chamber daily 5. monitor closely for tubing that is kinked or obstructed by the weight of the client
2, 3, 5 Rationale: chest tube tubing is never pinned to the bed linens because this presents the risk of accidental dislodgement of the tube when the client moves. the chest tube system is not opened and emptied because a closed system must be maintained; if the system is opened, lung collapse can occur
A LPN is preparing to assist a RN with removing a NG tube from the client. The lpn should reinforce instructing the client to perform which action? 1. exhale 2. inhale and exhale quickly 3. take and hold a deep breath 4. perform valsalva's maneuver
3 Rationale: when the NG tube is removed, the client is instructed to take and hold a deep breath. this will close the epiglottis, and the airway will be temporarily obstructed during the tube removal. this allows for the easy withdrawal of the tube through the esophagus into the nose. the tube is removed with one very smooth, continuous pull
The nurse is assigned to assist the HCP with the removal of a chest tube. The nurse should reinforce instructing the client to do which during this process? 1. stay very still 2. exhale forcefully 3. inhale and exhale quickly 4. perform valsalva's maneuver
4 Rationale: when the chest tube is removed, the client is asked to perform Valsalva's maneuver (take a deep breath, exhale, and bear down), the tube is quickly withdrawn, and an airtight dressing is taped in place. an alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed
