Advanced Skills Exam: Chest Tubes

A chest tube is inserted into a client who was stabbed in the chest and is attached to a closed-drainage system. Which is an important nursing intervention when caring for this client? a. Observe for fluid fluctuations in the water-seal chamber. b. Obtain a prescription for morphine to minimize agitation. c. Apply a thoracic binder to prevent excessive tension on the tube. d. Clamp the tubing securely to prevent a rapid decline in pressure.

a Fluctuations occur with inspiration and expiration until the lung is fully expanded. If these fluctuations do not occur, the chest tube may be clogged or kinked; coughing should be encouraged.

A client has chest tubes attached to a chest tube drainage system. What should the nurse do when caring for this client? a. Clamp the chest tubes when suctioning b. Palpate the surrounding area for crepitus c. Change the dressing daily using aseptic technique d. Empty the drainage chamber at the end of the shift

b Leakage of air into the subcutaneous tissue is evidenced by a crackling sound when the area is gently palpated. This is referred to as crepitus.

When a client suffers a complete pneumothorax, there is danger of a mediastinal shift. If such a shift occurs, what potential effect is a cause for concern? a. Rupture of the pericardium b. Infection of the subpleural lining c. Decreased filling of the right heart d. Increased volume of the unaffected lung

c Pressure within the pleural cavity causes a shift of the heart and great vessels to the unaffected side. This not only decreases the capacity of the unaffected lung but also impedes the filling of the right side of the heart and leads to a decreased cardiac output.

A client is diagnosed with a spontaneous pneumothorax. Which physiologic effect of a spontaneous pneumothorax should the nurse include in a teaching plan for the client? a. Air will move from the lung into the pleural space b. The heart and great vessels shift toward the affected side c. There is greater negative pressure within the chest cavity d. Collapse of the other lung will occur if not treated immediately

a As a person with a tear in the lung inhales, air moves through that opening into the intrapleural space. This creates a positive pressure and causes partial or complete collapse of the lung.

What clinical indicators should the nurse expect to identify when assessing an individual with a spontaneous pneumothorax? Select all that apply. a. Hematemesis b. Shortness of breath c. Unilateral chest pain d. Increased thoracic motion e. Mediastinal shift toward the involved side

b, c With the reduction of surface area for gaseous exchange the client experiences shortness of breath, tachycardia, and rapid, shallow respirations. Sudden chest pain occurs on the affected side; it may also involve the arm and shoulder.

A patient has a chest tube in place. What does the water in the water seal chamber do when the system is functioning correctly? a. Bubbles vigorously and continuously b. Bubbles gently and continuously c. Fluctuates with the patient's respirations d. Stops fluctuation, and bubbling is not observed

c

A client with emphysema experiences a sudden episode of shortness of breath and is diagnosed with a spontaneous pneumothorax. The client asks, "How could this have happened?" What likely cause of the spontaneous pneumothorax should the nurse's response take into consideration? a. Pleural friction rub b. Tracheoesophageal fistula c. Rupture of a subplueural bleb d. Puncture wound of the chest wall

c The etiology of a spontaneous pneumothorax is commonly the rupture of blebs on the lung surface. Blebs are similar to blisters, but are filled with air.

During the first 36 hours after the insertion of chest tubes, when assessing the function of a three-chamber, closed-chest drainage system, the nurse identifies that the water in the underwater seal tube is not fluctuating. What initial action should the nurse take? a. Take the client's vital signs. b. Inform the health care provider. c. Turn the client to the unaffected side. d. Check the tube to ensure that it is not kinked.

d Once the drainage tube is patent, the fluctuation in the water column will resume; a lack of fluctuation because of lung reexpansion is unlikely 36 hours after a traumatic open chest injury.

How should the nurse monitor for the complication of subcutaneous emphysema after the insertion of chest tubes? a. Palpate around the tube insertion sites for crepitus b. Auscultate the breath sounds for crackles and rhonchi c. Observe the client for the presence of a barrel-shaped chest d. Compare the length of inspirations with the length of expiration

a Subcutaneous emphysema occurs when air leaks from the intrapleural space through the thoracotomy or around the chest tubes into the soft tissue; crepitus is the crackling sound heard when tissues containing gas are palpated.

A client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department chest tubes are inserted, one in the second intercostal space and one at the base of the lung. What does the nurse expect the tube in the second intercostal space to accomplish? a. Remove the air that is present in the intrapleural space b. Drain serosanguinous fluid from the intrapleural compartment c. Permit the development of positive pressure between the layers of the pleura d. Provide access for the instillation of medication into the pleural space

a air rises and is removed via a tube inserted in the upper intrapleural space.

The nurse is caring for a patient with a chest tube. What is the correct nursing intervention for this patient? a. The patient is encouraged to cough and do deep-breathing exercises frequently b. "Stripping" of the chest tubes is done routinely to prevent obstruction by blood clots c. Water level in the suction chamber need not be monitored, just the collection chamber d. Drainage containers are positioned upright or on the bed next to the patient

a

The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would the nurse clearly instruct the nursing student to report immediately? a. Chest tube drainage of 10 to 15 mL/hr b. Continuous bubbling in the water-seal chamber c. Reports of pain at the chest tube site d. Chest tube dressing dated yesterday

b Continuous bubbling indicates an air leak that must be identified. With the health care provider's order, an RN can apply a padded clamp to the drainage tubing close to the occlusive dressing. If the bubbling stops, the air leak may be at the chest tube insertion. which will require the RN to notify the health care provider. If the air bubbling does not stop when the RN applies the padded clamp, the air leak is between the clamp and the drainage system, and the RN must assess the system carefully to locate the leak. Chest tube drainage of 10 to 15 mL/hr is acceptable. Chest tube dressings are not changed daily but may be reinforced. The patient's reports of pain need to be assessed and treated. This is important butt is not as urgent as investigating a chest tube leak.

The physician's prescriptions indicate an increase in the suction to -20 cm for a patient with a chest tube. To implement this, the nurse performs which intervention? a. Increases the wall suction to the medium setting and observes gentle bubbling in the suction chamber b. Adds water to the suction and drainage chambers to the level of -20 cm c. Stops the suction, adds sterile water to the level of -20 cm in the water seal chamber and resumes the wall suction d. Has the patient cough and deep-breathe and monitors the level of fluctuation to achieve -20 cm

c

The nurse is caring for a patient with a chest tube in place. Over the past hour the drainage from the tube was 110 mL. What is the nurse's best action? a. Gently "milk" the tubing to remove clots b. Check the chest tube system for leaks c. Instruct the patient to cough and deep-breathe d. Notify the surgeon immediately

d

Upon observation of a chest tube setup, the nurse reports to the provider that there is a leak in the chest tube and system. How has the nurse identified this problem? a. Drainage in the collection chamber has decreased b. The bubbling in the suction chamber has suddenly increased c. Fluctuation in the water seal chamber has stopped d. There was onset of continuous vigorous bubbling in the water seal chamber

d