NCM 112 RLE - Chest Tubes (NCLEX)
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
A client 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
A health care provider (HCP) tells the nurse that a client's chest tube is to be removed. The nurse should bring which dressing materials to the bedside for the HCP's use? 1.Telfa dressing and Neosporin ointment 2.Petrolatum gauze and sterile 4 × 4 gauze 3.Benzoin spray and a hydrocolloid dressing 4.Sterile 4 × 4 gauze, Neosporin ointment, and tape
2
The nurse is caring for a patient with a chest tube. The nurse knows that the drainage system is working correctly if she Observes? 1. Continuous bubbling in the waterseal chamber. 2. Intermittent bubbling in the waterseal chamber. 3. No bubbling appears in the suction chamber. 4. Titling is absent in the waterseal chamber.
2
The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action? 1.Check for an air leak. 2.Document the findings. 3.Notify the health care provider. 4.Change the chest tube drainage system.
2
The nurse is providing instructions to a client being discharged from the hospital following removal of a chest tube that was inserted after thoracic surgery. Which statement, if made by the client, indicates a need for further teaching? 1."I should avoid heavy lifting for at least 4 to 6 weeks." 2."I should remove the chest tube site dressing as soon as I get home." 3."If I have any difficulty in breathing, I should call the health care provider." 4."If I note any signs of infection, I should contact the health care provider (HCP)."
2
Which should the nurse do when caring for a client with chest tubes attached to a chest drainage system? 1.Empty the drainage collection chamber every shift. 2.Ensure the water level in the water seal chamber is at the 2-cm level. 3.Maintain the drainage collection device at the level of the client's chest. 4.Clamp the chest tube before moving the client from the bed to the chair.
2
A nursing student is developing a plan of care for a client with a chest tube that is attached to a Pleur-Evac drainage system. Which intervention in the care plan indicates the need for further teaching for the student? 1.Position the client in semi-Fowler's position. 2.Add water to the suction chamber as it evaporates. 3.Instruct the client to avoid coughing and deep breathing. 4.Tape the connection sites between the chest tube and the drainage system.
3
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.
3
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? Select all that apply. 1.Excessive bubbling in the water seal chamber 2.Vigorous bubbling in the suction control chamber 3.Drainage system maintained below the client's chest 4.50 mL of drainage in the drainage collection chamber 5.Occlusive dressing in place over the chest tube insertion site 6.Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation
3456
A client has a chest tube attached to a water seal drainage system. As part of routine nursing care, the nurse should ensure that which intervention is implemented? 1.The water seal chamber has continuous bubbling, and assessment for crepitus is done once a shift. 2.The amount of drainage into the chest tube is noted and recorded every 24 hours in the client's record. 3.The suction control chamber has sterile water added every shift, and the system is kept below waist level. 4.The connection between the chest tube and the drainage system is taped, and an occlusive dressing is maintained at the insertion site.
4
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.
4
The nurse caring for a client with a closed chest drainage system notes that the fluctuation (tidaling) in the water-seal compartment has stopped. On the basis of this assessment finding, the nurse would suspect which occurrence? 1.The system needs changing. 2.Suction needs to be increased. 3.Suction needs to be decreased. 4.The chest tubes are obstructed.
4
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? 1.Exhale slowly. 2.Stay very still. 3.Inhale and exhale quickly. 4.Perform the Valsalva maneuver.
4 When the chest tube is removed, the client is asked to perform the Valsalva 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.
For a male client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the plan of care? a. Measuring and documenting the drainage in the collection chamber b. Maintaining continuous bubbling in the water-seal chamber c. Keeping the collection chamber at chest level d. Stripping the chest tube every hour
A
The OR nurse is setting up a water-seal chest drainage system for a patient who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system? A) 20 cm H2O B) 15 cm H2O C) 10 cm H2O D) 5 cm H2O
A
The nurse is caring for a male client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do? A. Place the end of the chest tube in a container of sterile saline B. Apply an occlusive dressing and notify the physician. C. Clamp the chest tube immediately D. Secure the chest tube with tape
A
Two hours after surgery the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 mL of dark-red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform? A: Record the amount and continue to monitor drainage B: Notify the health care provider C: Strip the chest tube starting at the chest D: Increase the suction by 10 mm Hg
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
A
A nurse educator is reviewing the indications for chest drainage systems with a group of medical nurses. What indications should the nurses identify? Select all that apply. A) Post thoracotomy B) Spontaneous pneumothorax C) Need for postural drainage D) Chest trauma resulting in pneumothorax E) Pleurisy
ABD
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.
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
B
After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. a) False b) True
B This much negative pressure is excessive and may cause excessive trauma, hypoxemia, and atelectasis.
While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of the patients closed chest-drainage system. What should the nurse conclude? A) The system is functioning normally. B) The patient has a pneumothorax. C) The system has an air leak. D) The chest tube is obstructed.
C
You have just finished assisting the physician in removing Mr. H's chest tube. While securing the dressing, you notice that Mr. H is having difficulty breathing. Upon examination, you note that his trachea has shifted to the left side of his throat. You suspect that Mr. H has developed: A) early acute respiratory failure. B) aspiration of secretions. C) a pneumothorax. D) a normal finding after chest tube removal.
C
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.
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
The student nurse diligently assesses her patient with a chest tube. She notices that the suction control chamber of the chest tube is not bubbling. What is the first thing this student should do? A) Document this normal finding B) Encourage the patient to cough and deep breathe C) Check the level of the suction on the wall D) Clamp the chest tube and call for help
C The level of suction is controlled by the amount of water in the suction control chamber. However, it would be prudent of the student nurse to check and see if the suction is even turned on. This portion of the chest tube should be gently bubbling, indicating the system is working. Coughing and deep breathing would not help turn the suction on. The student should never clamp the chest tube.
A client has a chest tube in place following a left lower lobectomy done after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the MOST appropriate nursing action? a. Clamp the chest tube b. Call the surgeon immediately c. Prepare for blood transfusion d. Continue to monitor the rate of drainage
D
A nurse is educating a patient in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the patient and the family that this drainage system is used for? A) Maintaining positive chest-wall pressure B) Monitoring pleural fluid osmolarity C) Providing positive intrathoracic pressure D) Removing excess air and fluid
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
D
The nurse is assessing a patient who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the patients respirations. How should the nurse best respond to this assessment finding? A) Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes. B) Inform the physician promptly that there is in imminent leak in the drainage system. C) Encourage the patient to do deep breathing and coughing exercises. D) Document that the chest drainage system is operating as it is intended.
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
D
You are the nursing instructor and you are taking your students to a unit where chest tubes are often in use. Which statement, if made by your students, is correct? A) "If a clot has formed in the tubing, it can be gently milked by fully completely compressing the tubing and milking it into the drainage container" B) "I should loop my patients tubing in order to keep it off of the floor" C) "Because my patient has a tube draining air out of their pleural space, it will not be necessary to have them use their incentive spirometer" D) "There can be an occasional bubble form in the water seal chamber of the chest tube"
D An occasional bubble formed in the water seal chamber indicates that air is being released from the pleural spaces. Gentle milking of the tube may be permitted, but the tube should never be fully compressed to do it. Looping or kinking of the tube may cause a backward pressure that could impede drainage or force air back into the pleural spaces. Incentive spirometer use will help improve lung expansion.
The nurse sees the level of water in the water seal chamber rising very high. The nurse correlates which patient behavior with this rise? A) The patient is eating his lunch B) The patient is resting on his side C) The patient is squeezing the tubing D) The patient is coughing viciously.
D Coughing, sneezing or other forces can cause an increase in negative pressure which will in turn cause an increase in the water in the water seal chamber. Eating or resting should not affect the negative pressure in the tube. Squeezing, kinking, or somehow cutting off the flow into the chest tube would increase positive pressure, not negative.
A nurse providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this situation? a) Notify the physician. b) Apply an occlusive dressing on the site. c) Assess the patient for signs of respiratory distress. d) Put on gloves and insert the chest tube in a bottle of sterile saline.
D When a chest tube becomes separated from the drainage device, the nurse should first put on gloves, open a sterile bottle of normal saline or water, and insert the chest tube into the bottle without contaminating the chest tube. This creates a water seal until a new drainage unit can be attached. Then the nurse should assess vital signs and notify the physician.
