ATI Closed chest drainage Pretest

A nurse is caring for a patient who has a chest tube in place attached to water-seal drainage. Which of the following observations about the drainage should be reported if found 5 hr after insertion?

About 150 mL/hr over the past 2 hr. After the first few hours, the nurse should report drainage that exceeds 70 mL/hr. Patients who lose as much as 100 mL of blood every 15 min might require autotransfusion within 6 hr.

A nurse is caring for a patient who has a chest tube in place attached to a closed-chest water-seal drainage system following thoracic surgery. Which of the following strategies should the nurse use to help promote comfort for this patient?

A. Have the patient splint the affected side during coughing. It is essential for a patient with a chest tube to cough, not only to prevent postoperative complications but also to help drain the pleural space and expand the lungs. Splinting the affected side, such as with a pillow, can help minimize the pain of coughing. The nurse should also administer analgesia to help reduce the pain of coughing and other activities.

A nurse is assessing a patient who has a chest tube in place attached to a closed-chest water-seal drainage system. When the nurse palpates the area around the chest-tube insertion site, she is checking for?

B. Subcutaneous emphysema. Palpating the area surrounding the insertion site helps identify crepitus, a dry, crackling, or grating sound. This is the classic manifestation of subcutaneous emphysema, which indicates that air is leaking into the subcutaneous tissue surrounding the chest-tube insertion site.

While providing care for a patient who has a chest tube in place attached to a closed-chest drainage system, the nurse accidentally disconnects the chest tube from the system. Which of the following should the nurse do to prevent a serious complication while preparing to reconnect the system?

B. Submerge the end of the chest tube in 1 inch of sterile water. This action creates a water seal and prevents air from entering the pleural space through the open end of the chest tube when the patient inhales.

A nurse is caring for a patient who is 6 hr postoperative and has a chest tube in place attached to a closed-chest water-seal drainage system. The nurse should observe for which of the following indications of a problem in the drainage system?

Continuous bubbling in the water-seal chamber. Excessive and continuous bubbling in the water-seal chamber indicates an air leak in the drainage system. The nurse should use rubber-tipped clamps to try to locate the leak by clamping the tube momentarily at various points along its length.

A patient injured in a motor-vehicle crash is transported to an emergency department. The provider determines the need for immediate thoracotomy and chest-tube insertion and anticipates the need for maximal suction pressure. The appropriate type of closed-chest drainage system for this patient is a?

D. Dry suction-control system. Systems that use dry suction control allow for higher suction pressures by adjusting a dial on the front surface of the system to deliver suction pressure up to -40 cm of water. Some patients need high suction pressures due to a massive air leak from the lung surface, emphysema or viscous pleural effusion, or a reduction in pulmonary compliance.

A nurse is planning education for a patient who has a chest tube in place attached to a closed-chest drainage system following surgery for lung cancer. Which of the following should the nurse emphasize to the patient when he is ready to ambulate freely?

Keep the collection device upright at all times. The closed-chest drainage system must be upright at all times to ensure that the tubing drains optimally and the system functions correctly.

A nurse is preparing to transport to radiology a patient who has a chest tube and a closed-chest wet-suction drainage system. The provider allows disconnecting the drainage system from the suction source during transportation. Which of the following must the nurse do when detaching the suction source?

Make sure the air vent is open. Some closed-chest drainage systems and suction devices contain a vent from the water-seal chamber. This allows the drainage unit to remain vented without suction. So, the nurse should make sure this exit vent is open when disconnecting the suction source. Other systems allow air to exit through the suction-control tubing. With these systems, the nurse should keep the suction-control tubing uncapped and free from occlusion to prevent a buildup of air inside the pleural cavity.