Exam 2: Pneumothorax & Hemothorax (NCLEX)

The nurse is providing immediate postprocedure care to a client who had a thoracentesis to relieve a tension pneumothorax that resulted from rib fractures. The goal is that the client will exhibit normal respiratory functioning, and the nurse provides instructions to assist the client toward this goal. Which client statement indicates that further instruction is needed? 1."I will lie on the affected side for an hour." 2."I can expect a chest x-ray exam to be done shortly." 3."I will let you know at once if I have trouble breathing." 4."I will notify you if I feel a crackling sensation in my chest."

1

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.

1

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 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.

A nurse enters the room of a patient with a left-sided pneumothorax to perform an afternoon assessment. The nurse finds the patient's trachea deviated slightly to the right side compared to her morning findings, and the patient reports feeling increasingly short of breath. What is the first action the nurse should take? 1) Administer high-flow supplemental oxygen. 2) Position the patient's HOB at 30-45 degrees. 3) Call the physician. 4) Document the extent of tracheal shift in the patient's chart and reassess in 15 minutes.

1 High-flow supplemental oxygen should be administered immediately to offset the unavoidable result of hypoxemia. The nurse should also ensure a POX is applied. Adjusting the HOB will not adequately relieve the patient's shortness of breath.

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.

2

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.

2

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.

2 At three (3) days post-insertion, no fluctuation (tidaling) indicates the lung has reexpanded, which indicates the treatment has been effective.

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.

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.

A nurse walks in to a client who is in respiratory distress. The client has tracheal deviation to the right side. The nurse knows to prepare for which of the following emergent procedures? a. Chest tube insertion on the left side. b. Chest tube insertion on the right side. c. Intubation d. Tracheostomy

A

The nurse should include all of the following in the plan of care for the client with a chest tube r/t hemothorax? SATA: A) Report drainage of 100 ml/hr B) Teach the patient to cough and deep breath frequently C) Report intermittent bubbling in the water seal chamber D) Keep the patient on bedrest with bedside commode E) Loop tubing to keep it off of the floor

ABC

A patient is receiving mechanical ventilation with PEEP. The patient had developed a tension pneumothorax. Select ALL the signs and symptoms that can present with this condition: A. Hypotension B. Jugular Venous Distention C. Bradycardia D. Tracheal deviation E. Hyperemia F. Tachypnea

ABDF

A patient was admitted following a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax. Which are the most common assessment findings associated with a pneumothorax? (Select all that apply). A. Sharp pleuritic pain that worsens on inspiration B. Crackles over lung bases of affected lung C. Tracheal deviation toward the affected lung D. Worsening dyspnea E. Absent lung sounds to auscultation on affected side

ADE

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? a. A low respiratory rate b. Diminished breath sounds c. The presence of a barrel chest d. A sucking sound at the site of injury

B

You are asked to prepare Mr. W for a thoracentesis to relieve his left pleural effusion. He is very short of breath. Which position would be most appropriate for him during the procedure? A) Lying on his right side with his back flush to the edge of the bed B) Sitting on the side of the bed with his arms supported on the bedside table C) Lying prone with the head of the bed in Trendelenburg to facilitate drainage of fluids D) Lying supine with both arms place beneath the head

B

A patient has a chest tube for treatment of a pneumothorax in the left lung. Which finding during your assessment requires immediate nursing intervention? A. The water seal chamber has intermittent bubbling. B. The patient has slight tracheal deviation to the right side. C. The water seal chamber fluctuates while the patient inhales and exhales. D. The patient complains of tenderness at the chest tube insertion site.

B A patient with a chest tube is at risk for a tension pneumothorax due to the risk of pressure building up in the intrapleural space. Therefore, the nurse would want to monitor the patient for this and if tracheal deviation is present this is a major sign a tension pneumothorax. All the other options are normal findings. The water seal chamber will have intermittent (not excessive) bubbling because of the air that will be leaving the intrapleural space. The water seal chamber will flucutate up and down when the patient breathes in and out, and it is normal for the patient to have tenderness at the insertion site of the chest tube.

Which statement is CORRECT about a tension pneumothorax? A. This condition happens when an opening to the intrapleural space creates a two-way valve which causes pressure to build up in the space leading to shifting of the mediastinum. B. A tension pneumothorax is a medical emergency and is treated with needle decompression. C. Tracheal deviation is an early sign of a tension pneumothorax D. An open pneumothorax is the only cause of a tension pneumothorax.

B The only correct statement about a tension pneumothorax is option B. Option A is wrong because this condition happens when an opening to the intrapleural space creates a ONE-way (not two-way) valve which causes pressure to build up in the space leading to shifting of the mediastinum. Option C is wrong because tracheal deviation is a LATE (not early) sign of a tension pneumothorax. Option D is wrong because not only can an open pneumothorax cause a tension pneumothorax but a closed or spontaneous pneumothroax can as well.

A patient is admitted with a chest wound and experiencing extreme dyspnea, tachycardia, and hypoxia. The chest wound is located on the left mid-axillary area of the chest. On assessment, you note there is unequal rise and fall of the chest with absent breath sounds on the left side. You also note a "sucking" sound when the patient inhales and exhales. The patient's chest x-ray shows a pneumothorax. What type of pneumothorax is this known as? A. Closed pneumothorax B. Open pneumothorax C. Tension pneumothorax D. Spontaneous pneumothorax

B This description is of an open pneumothorax. An open pneumothorax happens when there is an opening in the chest wall ( from a gun shot, stabbing etc.) that creates a passage between the outside air and intrapleural space. This allow air to pass back and forth during inspiration and expiration. The body will shunt air through the opening in the chest well instead of the trachea (if the opening on the chest is large enough) which will create a "sucking" sound.

The patient has been diagnosed with having an open pneumothorax r/t penetrating injury. Which of the following symptoms would the nurse most expect to see in this patient? A) Chest pain and tracheal shifting B) Hyperresanance and hyperexpansion of the affected side C) High pitched respiratory sounds and SpO2 89% D) Muffled heart sounds and bradycardia

C An open pneumothorax is often also known as a sucking chest wound, producing a high pitched sucking sound coming from the wound. Diminished oxygen level, hyperresanance, and chest pain would also be expected in this patient. Tracheal shifting and hyperexpansion of the lung may be seen in a tension pneumothorax (an unlikely development of an open pneumothorax). Tachycardia, rather than bradycardia would be a common symptom in pneumothorax.

A patient is diagnosed with a primary spontaneous pneumothorax. Which of the following is NOT a correct statement about this type of pneumothorax? A. It can be caused by the rupture of a pulmonary bleb. B. It can occur in patients who are young, tall and thin without a history of lung disease. C. Smoking increases the chances of a patient developing a spontaneous pneumothorax. D. It is most likely to occur in patients with COPD, asthma, and cystic fibrosis

D

A patient receiving treatment for a pneumothorax calls on the call light to tell you something is wrong with their chest tube. When you arrive to the room you note that the drainage system has fallen on its side, and there is a large crack in the system. What is your next PRIORITY? A. Place the patient in supine position and clamp the tubing. B. Notify the physician immediately. C. Disconnect the drainage system and get a new one. D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.

D

A patient has come into the ED with a hemothorax and has had a chest tube inserted 2 hours ago. Which of the following would be most concerning if observed by the nurse? A) Tidaling in the water seal of the chest tube with a popping sensation in the skin around the chest tube B) The patient is complaining of pain 8/10 and is taking shallow breaths with a RR of 27 C) There is intermittent bubbling in the water seal of the chest tube with 200 ml of bright red drainage D) The patient begins to pick at his IV lines and tries to get out of bed and is sweating profusely

D Restlessness and Diaphoresis symptoms of hypoxemia and possible development of ARF. This requires immediate intervention. Tidaling in the water seal portion of the chest tube and subcutaneous emphysema are normal/benign findings and should be documented. Severe pain and elevated RR would be expected in this patient, but should be monitored for worsening severity. While 200 ml of bright red drainage would be expected after immediate insertion of the chest tube, intermittent bubbling would NOT be expected in the case of hemothorax. This indicates and air leak and should be investigated, but is not the most concerning in this situation.

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 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.

245

The nurse is caring for a patient after thoracentesis. Which actions can be delegated from the nurse to the unlicensed assistive personnel (UAP)? Select all that apply. 1.) Assess puncture site and dressing for leakage. 2.)Check vital signs every 15 minutes for 1 hour. 3.) Auscultate for absent or reduced lung sounds. 4.)Remind the patient to take deep breaths. 5.)Take the specimens to the laboratory. 6.) Teach the patient symptoms of pneumothorax.

245

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.

3

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? 1.Cyanosis 2.Hypotension 3.Paradoxical chest movement 4.Dyspnea, especially on exhalation

3 Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest.

The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is most appropriate? 1.Do nothing, because this is an expected finding. 2.Check for an air leak because the bubbling should be intermittent. 3.Increase the suction pressure so that the bubbling becomes vigorous. 4.Immediately clamp the chest tube and notify the health care provider.

4

A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube? A) To remove air from the pleural space B) To drain copious sputum secretions C) To monitor bleeding around the lungs D) To assist with mechanical ventilation

A

A patient was admitted after a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax, which includes which of the following? A: Sharp pleuritic pain that worsens on inspiration B: Crackles over lung bases of affected lung C: Tracheal deviation toward the affected lung D: Increased diaphragmatic excursion on side of rib fractures

A

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.

A

A patient enters the ED presenting with symptoms of shortness of breath, severe chest pain, and diminished heart sounds. His blood pressure is 90/70 and his heart rate is 110. You notice that the trachea appears to be deviated to the right. What is your nursing priority? A) Prepare for an emergency insertion of a needle into the second intercostal space, midclavicular line B) Hang IV fluids and prepare for chest tube insertion C) Encourage patient to breathe into a paper bag and obtain ABG's. D) Assess for allergies and administer epinephrine as ordered

A This patient is presenting with symptoms of a tension pneumothorax. In this emergent situation, a needle can be inserted at the second intercostal space, midclavicular line to immediately allow some air to flow out of the pleural space. A chest tube would then be inserted. The lung re-expansion would correct the abnormal blood pressure and heart rate, and the patient does not appear to be having an allergic reaction.

While caring for a patient with a suspected pneumothorax, you note there are several areas on the patient's skin that appear to be "bulging" out. These "bulging" areas are located on the patient's neck, face, and abdomen. On palpation on these areas, you note they feel "crunchy". When charting your findings you would refer to this finding as? A. Subcutaneous paresthesia B. Pigment molle C. Subcutaneous emphysema D. Veisalgia

C

The nurse is taking care of the patient with a pneumothorax. Which of the following, if found in the patients history, would be most contributory to the development of this pneumothorax? A) MVA involvement approximately 2 weeks ago. B) Hx of diabetes, HTN, and asthma C) Insertion of subclavian line yesterday D) Daily use of albuterol and corticosteroid inhaler

C Insertion of a subclavian line is often associated with traumatic pneumothorax. Some other procedures that may also cause this condition include throracentesis, endotracheal intubation, or transbronchial lung biopsy

You're providing care to a patient with a pneumothorax who has a chest tube. On assessment of the chest tube system, you note there is no fluctuation of water in the water seal chamber as the patient inhales and exhales. You check the system for kinks and find none. What is your next nursing action? A. Keep monitoring the patient because this is a normal finding. B. Increase wall suction to the system until the water fluctuates in the water seal chamber. C. Assess patient's lung sounds to assess if the affected lung has re-expanded. D. Notify the physician.

C It is normal for the water seal chamber to tidal up and down as the patient breathes in and out. If there is no fluctuation of water in the water seal chamber there may be a kink in the tubing or the lung has re-expanded. Therefore, it is important to check the system for kinks and if there are none then check the patient's lung sounds to see if lung sounds are present on the affected side (hence the lung has re-expanded).

Your patient with chronic obstructive pulmonary disease suddenly complains of sharp pain that began with a coughing fit. You know the doctor will require the following: a) Surgical consent for lobectomy b) Nothing- this is normal c) Chest tube set-up d) Ventilator set-up

C Patients with COPD and certain other chronic lung conditions are at a high risk for spontaneous pneumothorax. A chest tube would be needed to treat this condition.

The patient has an open pneumothorax. Which of the following options below is a nursing intervention you would provide to this patient? A. Place the patient in supine position B. Place a non-occlusive dressing over the chest wound C. Place a sterile occlusive dressing over the chest wound and tape it on three sides D. Prepare the patient for a thoracentesis

C The nursing intervention would be to place a sterile occlusive dressing over the wound and tape it on 3 sides (leaving one side NOT taped). This will allow exhaled air to leave the opening but seal over the opening when inhaling (hence not letting pressure build in the intrapleural space and prevent a tension pneumothorax).

Which of the following is a LATE sign of the development of a tension pneumothorax? A. Hypotension B. Tachycardia C. Tracheal deviation D. Dyspnea

C With a tension pneumothorax, you will quickly see hypotension, tachycardia, and dyspnea as the mediastinum shifts from the extra pressure in the intrapleural space on the affected side. A late sign of a tension pneumothorax is that the trachea will eventually shift to the unaffected side.

A thoracentesis is performed on a chest-injured client, and no fluid or air is found. Blood and fluids is administered intravenously (IV), but the client's vital signs do not improve. A central venous pressure line is inserted, and the initial reading is 20 cm H^O. The most likely cause of these findings is which of the following? A. Spontaneous pneumothorax B. Ruptured diaphragm C. Hemothorax D. Pericardial tamponade

D The reading of CVP of 20 means that there increased venous pressure backing up because the heart is not pumping effective. This would indicate the presence of cardiac tamponade.