NUR 210 (M1) - Chest Tubes & Pneumothorax
Which intervention should the nurse implement for a male client who has had a left-sided chest tube for six (6) hours and who refuses to take deep breaths because of the pain? 1. Medicate the client and have the client take deep breaths. 2. Encourage the client to take shallow breaths to help with the pain. 3. Explain deep breaths do not have to be taken at this time. 4. Tell the client if he doesn't take deep breaths, he could die.
1. Medicate the client and have the client take deep breaths Rationale 1. The client must take deep breaths to help push the air out of the pleural space into the water-seal drainage, and deep breaths will help prevent the client from developing pneumonia or atelectasis. 2. The client must take deep breaths; shallow breaths could lead to complications. 3. Deep breaths must be taken to prevent complications. 4. This is a cruel intervention; the nurse can medicate the client and then encourage deep breathing. If the test taker reads options "2" and "3" and notices that both reflect the same idea—namely, that deep breaths are not necessary—then both can either be eliminated as incorrect answers or kept as possible correct answers. Option "4" should be eliminated based on being a very rude and threatening comment.
A patient is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect? 1. Serous 2. Bloody 3. Serosanguineous 4. Bloody, with frequent small clots
2, In the first few hours after surgery, the drainage from the chest tube is bloody. After several hours, it becomes serosanguineous. The patient should not experience frequent clotting. Proper chest tube function should allow for drainage of blood before it has the chance to clot in the chest or tubing.
125. A client who is recovering from chest trauma is to be discharged home with a chest tube drainage system intact. The nurse should instruct the client to call the physician for which of the following? 1. Respiratory rate greater than 16 breaths/min. 2. Continuous bubbling in the water-seal chamber. 3. Fluid in the chest tube. 4. Fluctuation of fluid in the water-seal chamber.
2. Continuous bubbling in the water-seal chamber indicates a leak in the system, and the client needs to be instructed to notify the physician if continuous bubbling occurs. A respiratory rate of more than 16 breaths/min may not be unusual and does not necessarily mean that the client should notify the physician. Fluid in the chest tube is expected, as is fluctuation of the fluid in the water-seal chamber.
The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client? 1. A low respiratory rate 2. Diminished breath sounds 3. The presence of a barrel chest 4. A sucking sound at the site of injury
2. Diminished breath sounds Rationale: This client has sustained a blunt or closed-chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyper-resonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.
The alert and oriented client is diagnosed with a spontaneous pneumothorax, and the health- care provider is preparing to insert a left-sided chest tube. Which intervention should the nurse implement first? 1. Gather the needed supplies for the procedure. 2. Obtain a signed informed consent form. 3. Assist the client into a side-lying position. 4. Discuss the procedure with the client.
2. Obtain a signed informed consent form. Rationale: 1. The nurse should gather a thoracotomy tray and the chest tube drainage system and take it to the client's bedside, but it is not the first intervention. 2. The insertion of a chest tube is an invasive procedure and requires informed consent. Without a consent form, this procedure should not be done on an alert and oriented client. 3. This is a correct position to place the client in for a chest tube insertion, but it is not the first intervention. 4. The health-care provider will discuss the pro- cedure with the client, then informed consent must be obtained, and the nurse can do fur- ther teaching.
The unlicensed assistive personnel (UAP) assists the client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention from the nurse? 1. The UAP keeps the chest tube below chest level. 2. The UAP has the chest tube attached to suction. 3. The UAP allowed the client out of the bed. 4. The UAP uses a bedside commode for the client.
2. The UAP has the chest tube attached to suction. Rationale: 1. Keeping the drainage system lower than the chest promotes drainage and prevents reflux. 2. The chest tube system can function as a result of gravity and does not have to be attached to suction. Keeping it attached to suction could cause the client to trip and fall. Therefore, this is a safety issue and the nurse should intervene and explain this to the UAP. 3. Ambulation facilitates lung ventilation and expansion; drainage systems are portable to allow ambulation while chest tubes are in place. 4. The client should ambulate, but getting up and using the bedside commode is better than staying in the bed, so no action would be needed.
The nurse is presenting a class on chest tubes. Which statement best describes a tension pneumothorax? 1. A tension pneumothorax develops when an air- filled bleb on the surface of the lung ruptures. 2. When a tension pneumothorax occurs, the air moves freely between the pleural space and the atmosphere. 3. The injury allows air into the pleural space but prevents it from escaping from the pleural space. 4. A tension pneumothorax results from a puncture of the pleura during a central line placement.
3. The injury allows air into the pleural space but prevents it from escaping from the pleural space. Rationale: 1. This statement describes a spontaneous pneumothorax. 2. This statement describes an open pneumothorax. 3. This describes a tension pneumothorax. It is a medical emergency requiring immediate intervention to preserve life. This is called an iatrogenic pneumothorax, which also may be caused by thoracentesis or lung biopsy. 4, A tension pneumothorax could occur from this procedure, but the statement does not describe a tension pneumothorax.
A nurse is preparing to care for a patient following chest tube placement. Which of the following items should be available in the patient's room? (Select all that apply) a. Oxygen b. Sterile water c. Hemostat clamps d. Indwelling urinary catheter e. Occlusive dressing
A-oxygen should be readily available in case the patient goes into respiratory distress. The nurse should monitor respirations, O2 saturation, and lung sounds B-if the chest tubing becomes disconnected, the end of the tubing should be placed in the sterile water to restore the water seal C-hemostat clamps should be available for the nurse to use to check for air leaks or clamp tubing as ordered by physician E-if the tubing becomes disconnected, the nurse should immediately place an occlusive dressing over the chest tube insertion site. This allows for air to escape and reduces the risk of developing a tension pneumothorax D-indwelling urinary catheter is not an indication for a patient with a chest tube
Which assessment data indicates that the chest tubes have been effective in treating the patient with a hemothorax who has a right sided chest tube for three days? a) There is gentle bubbling in the suction compartment b) There is no fluctuation (tidaling) in the water-seal compartment c) There is 250 mL of blood in the drainage compartment d) The client is able to deep breathe without any pain
B-no fluctuation indicates the lung has no longer collapsed, indicating that the treatment has been effective A-normal if hooked up to suction C-output is normal and documented every shift D-breathing normally without pain is great, but not necessarily an indication of resolution of the hemothorax
The nurse caring for a patient with a chest tube turns the patient to the side and the chest tube disconnects from the drainage container. The initial nursing action is to? a) Call the physician b) Place the end of the chest tube in a bottle of sterile water c) Immediately replace the chest tube system d) Place the sterile dressing over the disconnection site
B-place the end of the tube in a bottle of sterile water held below the level of the chest A-the physician can be notified later, after addressing the situation, and to report any adverse assessments C-the drainage system will need to be replaced, but system set up takes a little time, so placing tubing end in sterile water is still the initial action D-if the tube had dislodged at insertion site vs. the drainage container, this would be the primary action
The nurse is presenting a class on chest tubes, Which statement describes a tension pneumothorax? a) A tension pneumothorax develops when 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 from the pleural space d) A tension pneumothorax results from a puncture of the pleura during a central line placement
C-the injury allows a large amount of air into the pleural space, but prevents it from escaping the pleural space A-describes a spontaneous pneumothorax B-describes an open pneumothorax D-describes an iatrogenic pneumothorax
When caring for a patient with ARDS as a result of a urinary tract infection (UTI), the nurse is asked by the patient's family how a UTI could cause lung damage. Which response by the nurse is appropriate? a. The infection spread through the circulation from the urinary tract to the lungs b. The urinary tract infection produced toxins that damaged the lungs c. The infection caused a generalized inflammation that damaged the lungs d. The fever associated with the infection led to scar tissue formation in the lungs
C-The pathophysiologic changes that occur in ARDS are thought to caused by inflammatory and immune reactions that lead to changes at the alveolar-capillary membrane. ARDS is not directly caused by infection, toxins, or fever
3 items to keep at patient's bedside if they have a chest tube and drainage system.
bottle of sterile water 2 clamps (hemostat or blue clamps) petroleum gauze
Which intervention should the nurse implement first for the client diagnosed with a hemothorax who has had a right-sided chest tube for three (3) days and has no fluctuation (tidaling) in the water compartment? 1. Assess the client's bilateral lung sounds. 2. Obtain an order for a STAT chest x-ray. 3. Notify the health-care provider as soon as possible. 4. Document the findings in the client's chart.
1. Assess the client's bilateral lung sounds. Rationale: 1. Assessment of the lung sounds could indicate the client's lung has reexpanded because it has been three (3) days since the chest tube has been inserted. 2. This should be done to ensure the lung has reexpanded, but it is not the first intervention. 3. The HCP will need to be notified so the chest tube can be removed, but it is not the first intervention. 4. This situation needs to be documented, but it is not the first intervention.
A nurse is caring for a client with a left-sided chest tube attached to a wet suction chest tube system. Which observation by the nurse would require immediate intervention? 1. Bubbling in the suction chamber 2. Dependent loop hanging off the edge of the bed 3. Banded connections between tubing sections 4. Occlusive dressing over chest tube insertion site
2, A dependent loop creates pressure back up and prevents fluid from draining; this requires immediate intervention to prevent lung collapse. Bubbling in a wet suction chest tube system indicates that the suction is working and is an expected finding as are banded connections between sections of tubing. An occlusive dressing helps to prevent air from leaking into the subcutaneous space and maintains integrity of the closed drainage system.
The client had a right-sided chest tube inserted two (2) hours ago for a pneumothorax. Which action should the nurse implement if there is no fluctuation (tidaling) in the water-seal compartment? 1. Obtain an order for a STAT chest x-ray. 2. Increase the amount of wall suction. 3. Check the tubing for kinks or clots. 4. Monitor the client's pulse oximeter reading.
3. Check the tubing for kinks or clots. Rationale: 1. A STAT chest x-ray would not be needed to determine why there is no fluctuation in the water-seal compartment. 2. Increasing the amount of wall suction does not address why there is no fluctuation in the water-seal compartment. 3. The key to the answer is "2 hours." The air from the pleural space is not able to get to the water-seal compartment, and the nurse should try to determine why. Usually the client is lying on the tube, it is kinked, or there is a dependent loop. 4. The stem does not state the client is in respiratory distress, and a pulse oximeter reading detects hypoxemia but does not address any fluctuation in the water-seal compartment.
A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water-seal chest tube drainage system. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation? 1. An obstruction is present in the chest tube. 2. The client is developing subcutaneous emphysema. 3. The chest tube system is functioning properly. 4. There is a leak in the chest tube system.
3. Fluctuation of fluid in the water-seal column with respirations indicates that the system is functioning properly. If an obstruction were present in the chest tube, fluid fluctuation would be absent. Subcutaneous emphysema occurs when air pockets can be palpated beneath the client's skin around the chest tube insertion site. A leak in the system is indicated when continuous bubbling occurs in the water-seal column.
The physician has inserted a chest tube in a client with a pneumothorax. The nurse should evaluate the effectiveness of the chest tube: 1. For administration of oxygen. 2. To promote formation of lung scar tissue. 3. To insert antibiotics into the pleural space. 4. To remove air and fluid.
4. A chest tube is inserted to re-expand the lung and remove air and fluid. Oxygen is not administered through a chest tube. Chest tubes are not inserted to promote scar tissue formation. Antibiotics are not used to treat a pneumothorax.
Which of the following findings would suggest pneumothorax in a trauma victim? 1. Pronounced crackles. 2. Inspiratory wheezing. 3. Dullness on percussion. 4. Absent breath sounds.
4. Pneumothorax means that the lung has collapsed and is not functioning. The nurse will hear no sounds of air movement on auscultation. Movement of air through mucus produces crackles. Wheezing occurs when airways become obstructed. Dullness on percussion indicates increased density of lung tissue, usually caused by accumulation of fluid.
The nurse is caring for a client with a right- sided chest tube that is accidentally pulled out of the pleural space. Which action should the nurse implement first? 1. Notify the health-care provider to have chest tubes reinserted STAT. 2. Instruct the client to take slow shallow breaths until the tube is reinserted. 3. Take no action and assess the client's respiratory status every 15 minutes. 4. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site.
4. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site. 1. The health-care provider will have to be notified, but this is not the first intervention. Air must be prevented from entering the pleural space from the outside atmosphere. 2. The client should breathe regularly or take deep breaths until the tubes are reinserted. 3. The nurse must take action and prevent air from entering the pleural space. 4. Taping on three sides prevents the development of a tension pneumothorax by inhibiting air from entering the wound during inhalation but allowing it to escape during exhalation.
The nurse is caring for a patient with a chest tube connected to -20 cm suction. The chest tube is pulled out of the chest when a patient is getting out of bed. Which of the following actions should the nurse take first? 1. assess the RR and O2 sat. reading 2. place the chest tube in a bottle of sterile water. 3. call the rapid response team 4. cover the wound with petroleum gauze
4. cover the wound with petroleum gauze. The PRIORITY action would be to apply petroleum gauze over the site immediately and tape 3 of 4 sides to allow air to escape from the chest & preventing a tension pneumothorax and possible mediastinal shift. Not #2 because that would be done if the drainage system cracks and loses its water seal. You would quickly disconnect the chest tube from the atrium and submerge it in a bottle of sterile water until the system can be reestablished.
A nurse is caring for a patient 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
A-do nothing, continuous, gentle bubbling should be noted in the suction control chamber B-chest tubes should only be clamped to check for for an air leak, when changing drainage device or with a provider order C-bubbling should be continuous, not intermittent D-bubbling should be gentle
A nurse is caring for a patient who has a chest tube and drainage system in place. The nurse observes that the patient's chest tube was accidentally removed at the insertion site. Which of the following actions should the nurse take first? a. Place the tubing in the sterile water to restore the seal b. Apply sterile, occlusive gauze to the insertion site c. Place tape around the insertion site d. Assess the client's respiratory status
B -Using the ABC priority setting framework, the application of a sterile, occlusive gauze to the site should be the first action for the nurse to take. This allows for air to escape & reduces the risk of developing a tension pneumothorax A-appropriate if the tubing had become disconnected from the drainage tubing C-appropriate to keep gauze in place, but not first priority D-appropriate, but in this case, not the first priority
A nurse is assessing a patient who has a chest tube and drainage system in place. Which of the following are expected findings? (select all that apply) a. Continuous bubbling in the water seal chamber b. Gentle, continuous bubbling in the suction control chamber c. Rise and fall in the level of water in the water seal chamber with inspiration and expiration d. Exposed sutures without dressing e. Drainage system upright at chest level
B-gentle bubbling in the suction control chamber is an expected finding as air is being removed C-a rise and fall of the fluid level in the water seal chamber upon inspiration & expiration indicates that the drainage system is functioning properly A-continuous bubbling in the water seal chamber indicates an air leak D-the nurse should cover the sutures at the insertion site with an airtight dressing E-the drainage system should be maintained in an upright position below the level of the patients chest
The patient had a right sided chest tube inserted 2 hours ago for a pneumothorax. Which action should the nurse take if 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 air from the pleural space is not able to get to the water seal chamber, and the nurse should try to determine why. Usually, the patient is laying on the tube, it is kinked, or there is a dependent twisted loop. A- an x-ray may be necessary, but as the tube has only been in 2 hours, the pneumothorax has probably not resolved enough to have no fluctuation B- an increase in wall suction has minimal effect on actual suction imposed on chest cavity D-important, but not first priority in this situation
4 things to assess when a patient has a chest drainage system in place.
check for: air leak in the underwater system fluctuations (tidaling) in the water seal drainage: volume, color consistency subQ emphysema (crepitus) of the insertion site on the patient
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? 1. Check the amount of wall suction being applied. 2. Assess the tubing for any blood clots. 3. Milk the tubing proximal to distal. 4. Encourage the client to cough forcefully
1. Check the amount of wall suction being applied. Rationale: 1. Checking to see if someone has increased the suction rate is the simplest and a noninvasive action for the nurse to implement; if it is not on high, then the nurse must check to see if the problem is with the client or the system. 2. No fluctuation (tidaling) would cause the nurse to assess the tubing for a blood clot. 3. The tube is milked to help dislodge a blood clot that may be blocking the chest tube, causing no fluctuation (tidaling) in the water- seal compartment. The chest tube is never stripped, which creates a negative air pressure and could suck lung tissue into the chest tube. 4. Encouraging the client to cough forcefully will help dislodge a blood clot blocking the chest tube, causing no fluctuation (tidaling) in the water-seal compartment.
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? Select all that apply. 1. Place the client in the low Fowler's position. 2. Assess chest tube drainage system frequently. 3. Maintain strict bed rest for the client. 4. Secure a loop of drainage tubing to the sheet. 5. Observe the site for subcutaneous emphysema.
2. Assess chest tube drainage system frequently. 4. Secure a loop of drainage tubing to the sheet. 5. Observe the site for subcutaneous emphysema. Rationale: 1. The client should be in the high Fowler's position to facilitate lung expansion. 2. The system must be patent and intact to function properly. 3. The client can have bathroom privileges, and ambulation facilitates lung ventilation and expansion. 4. Looping the tubing prevents direct pressure on the chest tube itself and keeps tubing off the floor, addressing both a safety and a potential clogging of the tube. 5. Subcutaneous emphysema is air under the skin, which is a common occurrence at the chest tube insertion site.
Which assessment data indicate to the nurse the chest tubes inserted three (3) days ago have been effective in treating the client with a hemothorax? 1. Gentle bubbling in the suction compartment. 2. No fluctuation (tidaling) in the water-seal compartment. 3. The drainage compartment has 250 mL of blood 4.The client is able to deep breathe without any pain.
2. No fluctuation (tidaling) in the water-seal compartment. Rationale 1. This is an expected finding in the suction compartment of the drainage system, indicating adequate suctioning is being applied. 2. At three (3) days postinsertion, no fluctuation (tidaling) indicates the lung has reexpanded, which indicates the treatment has been effective. 3. Blood in the drainage bottle is expected for a hemothorax but does not indicate the chest tubes have reexpanded the lung. 4. Taking a deep breath without pain is good, but it does not mean the lungs have reexpanded.
The client is admitted to the emergency department with chest trauma. Which signs/ symptoms indicate to the nurse the diagnosis of pneumothorax? 1. Bronchovesicular lung sounds and bradypnea. 2. Unequal lung expansion and dyspnea. 3. Frothy, bloody sputum and consolidation. 4. Barrel chest and polycythemia.
2. Unequal lung expansion and dyspnea.
A client has been in an automobile accident and the nurse is assessing the client for possible pneumothorax. The nurse should assess the client for: 1. Sudden, sharp chest pain. 2. Wheezing breath sounds over affected side. 3. Hemoptysis. 4. Cyanosis.
1. Pneumothorax signs and symptoms include sudden, sharp chest pain; tachypnea; and tachycardia. Other signs and symptoms include diminished or absent breath sounds over the affected lung, anxiety, and restlessness. Breath sounds are diminished or absent over the affected side. Hemoptysis and cyanosis are not typically present with a moderate pneumothorax.
A young adult is admitted to the emergency department after an automobile accident. The client has severe pain in the right chest where there was an impact on the steering wheel. Which is the primary client goal at this time? 1. Reduce the client's anxiety. 2. Maintain adequate oxygenation. 3. Decrease chest pain. 4. Maintain adequate circulating volume.
2. Blunt chest trauma may lead to respiratory failure, and maintenance of adequate oxygenation is the priority for the client. Decreasing the client's anxiety is related to maintaining effective respirations and oxygenation. Although pain is distressing to the client and can increase anxiety and decrease respiratory effectiveness, pain control is secondary to maintaining oxygenation. Maintaining adequate circulatory volume is also secondary to maintaining adequate oxygenation.
The nurse is caring for a client diagnosed with a pneumothorax who had chest tubes inserted four (4) hours ago. There is no fluctuating (tidaling) in the water-seal compartment of the closed chest drainage system. Which action should the nurse implement first? 1. Milk the chest tube. 2. Check the tubing for kinks. 3. Instruct the client to cough. 4. Assess the insertion site.
2. Check the tubing for kinks. The nurse should implement the least invasive intervention first. The nurse should check to see if the tubing is kinked, causing a blockage between the pleural space and the water-seal bottle.
A nurse should interpret which of the following as an early sign of a tension pneumothorax in a client with chest trauma? 1. Diminished Bilateral Breath Sounds. 2. Muffled heart sounds. 3. Respiratory distress. 4. Tracheal Deviation.
3. Respiratory distress or arrest is a universal finding of a tension pneumothorax. Unilateral, diminished, or absent breath sounds is a common finding. Tracheal deviation is an inconsistent and late finding. Muffled heart sounds are suggestive of pericardial tamponade.
