Chest Trauma Practice Questions

ANS: C A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance but should be done after the morphine is given.

40. The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first? a. Assist the patient to sit upright in a chair. b. Splint the patient's chest during coughing. c. Medicate the patient with prescribed morphine. d. Observe the patient use the incentive spirometer.

A. If there is an air leak from the lung into the pleural space, the dressing applied to the patient's chest should mimic the function of the chest drainage system - allow air to escape from the pleural space while minimizing air re-entering the pleura from the atmosphere. If an occlussive dressing was applied, no air could escape the pleural space and the pneumothorax could develop into a tension pneumothorax.

If the chest tube is pulled out of the patient's chest, and the patient had an air leak from the lung, after asking a colleague to call a physician STAT, emergency nursing management is to: A. Cover the opening with a sterile dressing, taped on three sides B. Cover the opening with a sterile Vaseline gauze, taped securely on all sides C. Leave the opening alone and monitor the patient until a physician can assess the situation D. Try to put the tube back in place as quickly as possible

C.

In a self-contained, disposable chest drain, the amount of negative pressure transmitted to the patient by suction is determined by: A. The amount of suction set on the wall vacuum regulator B. The sensitivity of the high negative pressure relief valve C. The dial setting on the suction control chamber D. The level of water in the water seal chamber

C.

In self-contained, disposable chest drains, the manual high negative pressure relief valve A. Allows water to be added to the system without disconnecting the patient tubing B. Alerts the nurse to a situation of high pressure within the system and automatically vents C. Allows filtered atmospheric air into the system to offset a rise in negative pressure D. Alerts the nurse to high suction levels accumulating in the system

A.

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

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.

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.

ANS: B 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.

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

ANS: A Paradoxic chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange.

22. A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment? a. Paradoxic chest movement b. Complaint of chest wall pain c. Heart rate of 110 beats/minute d. Large bruised area on the chest

ANS: D The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient's clinical manifestations are not consistent with these problems.

23. When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient? a. Emergency pericardiocentesis b. Stabilization of the chest wall with tape c. Administration of an inhaled bronchodilator d. Insertion of a chest tube with a chest drainage system

ANS: C Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction pressure. The amount of suction applied is regulated by the amount of water in this chamber and not by the amount of suction applied to the system.

24. A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is most appropriate? a. Document the presence of a large air leak. b. Notify the surgeon of a possible pneumothorax. c. Take no further action with the collection device. d. Adjust the dial on the wall regulator to decrease suction.

ANS: A Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 88% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low oxygen saturation is the priority.

31. The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider? a. Oxygen saturation is 88%. b. Blood pressure is 145/90 mm Hg. c. Respiratory rate is 22 breaths/minute when lying flat. d. Pain level is 5 (on 0 to 10 scale) with a deep breath.

ANS: B The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the left side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30 to 45 degrees to facilitate breathing.

39. A patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take? a. Position the patient so that the left chest is dependent. b. Tape a nonporous dressing on three sides over the chest wound. c. Cover the sucking chest wound firmly with an occlusive dressing. d. Keep the head of the patient's bed at no more than 30 degrees elevation.

ANS: A UAP education includes documentation of intake and output. The other actions are within the scope of practice and education of licensed nursing personnel.

48. The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Document the amount of drainage every eight hours. b. Obtain samples of drainage for culture from the system. c. Assess patient pain level associated with the chest tube. d. Check the water-seal chamber for the correct fluid level.

ANS: D The patient's history and symptoms suggest possible tension pneumothorax, a medical emergency. The other patients also require assessment as soon as possible, but tension pneumothorax will require immediate treatment to avoid death from inadequate cardiac output or hypoxemia.

49. After change-of-shift report, which patient should the nurse assess first? a. 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet b. 28-year-old with a history of a lung transplant and a temperature of 101° F (38.3° C) c. 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain d. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion

A.

A patient with an opening in the chest wall, such as from a gunshot, stab wound or impalement, resulting in "sucking chest wound" can be said to have: A. An open pneumothorax B. A closed pneumothorax C. A hemothorax D. A pleural effusion

D.

A physician has just performed a thoracostomy for a pleural effusion. The nurse handed the patient tubing from the drain to the physician, who attached it to the chest tube. The drain is properly filled with water and placed in an upright position below the patient's chest. The physician orders suction to the chest drain system. With a dry suction control chamber (as is present in the Atrium Oasis), how should the nurse adjust the vacuum source? A. Adjust the vacuum source until the dial on the vacuum regulator reads -20mmHg B. Adjust the vacuum source until constant, gentle bubbling just begins in the suction control chamber C. Adjust the vacuum source until the bellows indicator is all the way to the right of the indicator window D. Adjust the vacuum source until the bellows indicator reaches the arrow mark in the indicator window

D.

New bubbling is observed in the water seal chamber after a patient with a pleural chest tube returns from a test. The nurse clamps the chest tube momentarily with a tubing clamp at the dressing site. When this is done, bubbling in the water seal stops. The next appropriate nursing action is to: A. Continue to monitor the water seal chamber for bubbling every hour for the next four hours B. Do nothing. This bubbling is normal in patients with pleural chest tubes C. Call the physician immediately and do not leave the patient's bedside because of the risk of respiratory failure D. Remove the chest tube dressing to see if one or more eyelets of the chest tube have been pulled out of the chest

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 so requires informed con- sent. Without a consent form, this procedure cannot be done on an alert and oriented client. 3. This is a correct position to place the client for a chest tube insertion, but it is not the first intervention. 4. The physician will discuss the procedure with the client, then informed consent must be obtained, and then the nurse can do further teaching. TEST-TAKING HINT: The test taker must know that invasive procedures require informed consent and legally it must be obtained first before anyone can touch the client.

The alert and oriented client is diagnosed with a spontaneous pneumothorax, and the physician 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.

1. This pulse oximeter reading indicates the client is hypoxic and therefore is not stable and should be assigned to an RN. 2. This H&H are very low; therefore the client is not stable and should be assigned to an RN. 3. Jugular vein distention and hypotension are signs of a tension pneumothorax, which is a medical emergency, and the client should be assigned to an RN. ***4. A client that is two (2) hours post- bronchoscopy procedure could safely be assigned to an LPN. TEST-TAKING HINT: The test taker must under- stand that the LPN should be assigned the least critical client or the client that is stable and not exhibiting any complications second- ary to the admitting disease or condition.

The charge nurse is making client assignments on a medical floor. Which client should the charge nurse assign to the LPN? 1. The client with pneumonia who has a pulse oximeter reading of 91%. 2. The client with a hemothorax who has Hgb of 9 mg/dL and Hct of 20%. 3. The client with chest tubes who has jugular vein distention and BP of 96/60. 4. The client who is two (2) hours post-bronchoscopy procedure.

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 that the client is in respiratory distress, and a pulse oximeter read- ing detects hypoxemia but does not address any fluctuation in the water-seal compartment. TEST-TAKING HINT: The test taker should apply the nursing process to answer the question correctly. The first step in the nursing process is assessment and "check" (option "3") is a word that can be used synonymously for assess. Monitoring (option "4") is also assess- ing, but the test taker should not check a diagnostic test result before caring for the client.

The client had a right-sided chest tube inserted two (2) hours ago for a pneumothorax. Which action should the nurse take 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.

1. The health-care provider will have to be noti- fied, 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. TEST-TAKING HINT: The word "first interven- tion" in the stem of the question indicates to the test taker that possibly more than one (1) intervention could be indicated in the situa- tion but only one (1) is implemented first. Remember, do not select assessment first without reading the question. If the client is in any type of crisis, then the nurse should first do something to help the client's situation.

The client has a right-sided chest tube. As the client is getting out of the bed it is acci- dentally 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.

1. The client with pneumothorax would have absent breath sounds and tachypnea. ***2. Unequal lung expansion and dyspnea would indicate a pneumothorax. 3. Consolidation occurs when there is no air moving through the alveoli as in pneumonia; frothy sputum occurs with congestive heart failure. 4. Barrel chest and polycythemia are signs of chronic obstructive pulmonary disease. TEST-TAKING HINT: The test taker can use "chest trauma" or "pneumothorax" to help select the correct answer. Both of these words should cause the test taker to select "2" because unequal chest expansion would result from trauma.

The client is admitted to the emergency department with chest trauma. When assess- ing the client, which signs/symptoms would the nurse expect to find that support 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.

B.

The following would result in a loss of the water seal: A. Momentary tipping-over of the Atrium drainage system. B. Evaporation of the water in the water seal chamber below the 2 cm mark. C. Suction removed or turned off. D. The drainage chambers are full.

1. The client should be in a high-Fowler's posi- tion 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 pres- sure on the chest tube itself and keeps tubing off the floor, addressing both a safety and an infection control issue. ***5. Subcutaneous emphysema is air under the skin, which is a common occurrence at the chest tube insertion site. TEST-TAKING HINT: The test taker should be careful with adjectives. In option "1" the word "low" makes it incorrect; in option "3," the word "strict" makes this option incorrect.

The nurse is caring for a client with a right-sided chest tube secondary to a pneu- mothorax. Which interventions should the nurse implement when caring for this client? Select all that apply. 1. Place the client in a 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.

1. This is incorrect information. It is the description of a spontaneous pneumothorax. 2. This is the description of an open pneumothorax. ***3. This describes a tension pneumothorax. It is a medical emergency requiring immediate intervention to preserve life. 4. This is called an iatrogenic pneumothorax, which also may be caused by thoracentesis or lung biopsy. A tension pneumothorax could occur from this procedure, but it does not describe a tension pneumothorax. TEST-TAKING HINT: The test taker must always be clear about what the question is asking before answering the question. If the test taker can eliminate options "1" and "2" and can't decide between "3" and "4," the test taker must go back to the stem and clarify what the question is asking.

The nurse is presenting a class on chest tubes. Which statement 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.

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 nursing assistant. 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 stay- ing in the bed, so no action would be needed. TEST-TAKING HINT: "Warrants immediate intervention" means the test taker must identify the situation in which the nurse should intervene and correct the action, demonstrate a skill, or somehow intervene with the unlicensed assistant's behavior.

The unlicensed nursing assistant is assisting the client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention from the nurse? 1. The client's chest tube is below the level of the chest. 2. The nursing assistant has the chest tube attached to suction. 3. The nursing assistant allowed the client out of the bed. 4. The nursing assistant uses a bedside commode for the client.

C.

The water seal is the most important element of the drainage system because: A. It indicates patency of the tubing by tidaling with inspiration and expiration B. It allows air to enter the pleural space but prevent air from exiting the pleural space through the chest tube C. It allows air to exit the pleural space but prevent air from entering the pleural space through the chest tube D. It allows air to move freely in and out of the pleural space through the chest tube.

***1. Checking to see if someone has increased the suction rate is the simplest 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 would suck lung tissue into the chest tube. 4. Encouraging the client to cough force fully will help dislodge a blood clot that may be blocking the chest tube, causing no fluctuation (tidaling) in the water-seal compartment. TEST-TAKING HINT: The test taker should always think about assessing the client if there is a problem and the client is not in immediate danger. This would cause the test taker to eliminate options "3" and "4." If the test taker thinks about bubbling, he or she should know it has to do with suctioning.

Which action should the nurse implement for the client with a hemothorax who has a right-sided chest tube and there is 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. This is an expected finding in the suction compartment of the drainage system that indicates adequate suctioning is being applied. ***2. At three (3) days post-insertion, 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. TEST-TAKING HINT: The test taker must be knowledgeable about chest tubes to be able to answer this question. The test taker must know the normal time frame and what is expected for each compartment of the chest tube drainage system.

Which assessment data indicate that the chest tubes have been effective in treating the client with a hemothorax who has a right-sided chest tube? 1. There is gentle bubbling in the suction compartment. 2. There is no fluctuation (tidaling) in the water-seal compartment. 3. There is 250 mL of blood in the drainage compartment 4. The client is able to deep breathe without any pain.

***1. Assessment of the lung sounds could indi- cate that 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 that the lung has reexpanded, but it is not the first intervention. 3. The HCP will need to be notified so that 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. TEST-TAKING HINT: When the stem asks the test taker to identify the first intervention, all four (4) answer options could be interventions that are appropriate for the situation, but only one (1) is the first intervention. Remember to apply the nursing process: the first step is assessment.

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 fluctu- ation (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. 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 develop- ing 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. TEST-TAKING HINT: 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.

Which intervention should the nurse implement for a male client who has had a left- sided chest tube for six (6) hours and refuses to take deep breaths because it hurts too much? 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 that deep breaths do not have to be taken at this time. 4. Tell the client that if he doesn't take deep breaths, he could die.

C.

Which of the following signs indicates a chest tube may be removed? A. Drainage is approximately 100mL/hr in a patient with pleural chest tube following spinal surgery B. The chest radiograph shows only a small residual pneumothorax in a patient requiring mechanical ventilation C. Bubbling in the water seal has been absent for 24 hours following iatrogenic pneumothorax from CVP placement D. Fluctuations in the water seal are approximately 2 to 4cmH2O with each breathing cycle

B.

Which of the following situations is likely to result in an absence of fluctuations in the chest drainage tubing? A. The tubing is coiled on the bed with a straight path to the chest drain B. The tubing is blocked in some way C. The patient is receiving positive pressure ventilation D. The patient is ambulatory

D.

Which of the following statements is true about intrapleural (the space between the parietal and visceral or pulmonary pleurae) pressure under normal conditions? A. It is always positive B. It is negative during inhalation; positive during exhalation C. It is positive during inhalation; negative during exhalation D. It is always negative

D.

Which of the following statements is true regarding patient movement while requiring chest drainage? (assume a physician order or protocol exists) A. Patients may go only from bed to a chair while the chest tube is connected to a chest drain B. If patient must leave nursing unit, suction tubing should be clamped shut while chest drain is disconnected from suction C. If a patient is ambulatory, the chest tube should be clamped shut while the chest drain is disconnected from suction D. Patients may walk around once the nurse disconnects the drain from suction as long as the drain remains below the chest