Mechanical Ventilation, Chest Tube

When caring for a patient who has a pneumothorax, which of these actions should the healthcare provider include in the patient's plan of care? a. encourage the patient to deep breathe and cough regularly b. empty the drainage chamber every shift and record the amount c. change the insertion site dressing daily using aseptic technique d. vigorously massage the tube every 2 hours to promote drainage

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 patient is recovering from a pneumothorax and has a chest tube present. Which of the following is an appropriate finding when assessing the chest tube drainage system? A. Intermittent bubbling may be noted in the water seal chamber. B. 200 cc of drainage per hour is expected during recovery of a pneumothorax. C. The chest tube is positioned at the patient's chest level to facilitate drainage. D. All of these options are appropriate findings.

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

A

You're assessing a patient who is post-opt from a chest tube insertion. On assessment, you note there is 50 cc of serosanguinous fluid in the drainage chamber, fluctuation of water in the water seal chamber when the patient breathes in and out, and bubbling in the suction control chamber. Which of the following is the most appropriate nursing intervention? A. Document your findings as normal. B. Assess for an air leak due to bubbling noted in the suction chamber. C. Notify the physician about the drainage. D. Milk the tubing to ensure patency of the tubes.

A

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

A, B, D, F

You patient is ordered a chest x-ray to confirm endotracheal tube placement. The tube should be how many cm above the carina? A. 1-2 cm B. 0.5-1.5 cm C. 1-4 cm D. 2-3 cm

A. 1-2 cm

Which patient would benefit from a Nasogastric Tube? A. A stroke victim who failed their swallow evaulation B. A patient with Congestive Heart Failure C. A patient who had a left leg amputation D. A patient with a Platelet count of 50

A. A stroke victim who failed their swallow evaulation Patients who have suffered a stroke are at risk for aspiration. Therefore, they are assessed by a speech pathologist for swallowing abilities. If a patient fails a speech evaluation, they are at risk for aspiration. A nasogastric tube helps decrease the risk of aspiration.

You just inserted a Nasogastric tube. Which of the following is not a correct way to check correct placement of the tube? A. Administering a 100cc Water flush and assessing for patient coughing B. Obtaining a sample of GI contents through the tube by aspirating C. Following the MD order for an X-ray to confirm placement D. Checking pH of GI contents to be at 1 to 3.5

A. Administering a 100cc Water flush and assessing for patient coughing Due to the risk of aspiration, nothing should be flushed through a NG tube until placement of tube is confirmed.

A patient is placed on volume-cycled ventilation. The nurse plans care for this client based on which characteristic of this method of ventilation? A. Delivers a set volume, which will help overcome the client's airway resistance changes. B. The mechanism by which the phase of the breath switches from inspiration to expiration. C. Provides a consistent tidal volume. D. Delivers a preset volume of gas to the lungs to generate high pressures.

A. Delivers a set volume, which will help overcome the client's airway resistance changes. Rationale: Volume- cycled ventilation delivers a preset volume of gas to the lungs, making volume constant therefore, overcoming the changes in lung compliance and airway resistance.

A patient with a tracheostomy needs to be suctioned. What would you do first before suctioning the patient? A. Hyperoxygenate the patient before suctioning B. Assist the patient into Sim's position C. Disconnect pulse oximetry D. Have the patient bear down

A. Hyperoxygenate the patient before suctioning Before suctioning a patient with a tracheostomy you would need to hyperoxygenate the patient because during suctioning you will be decreasing the patient's oxygen supply.

Your patient has a PEG tube and you are about to administer a tube feeding using the feeding pump. You note that the last feeding tube hanging on the pole is labeled Aug 16 and today's date is Aug 18. Which nursing action is correct. A. Immediately discard the tubing and open a new package of tubing before proceeding with the feeding B. Continue to administer the feeding because the tubing is good for 4 days C. Change the adapter cap at the end of the tubing D. Notify the MD for further orders

A. Immediately discard the tubing and open a new package of tubing before proceeding with the feeding Tube feeding containers and tubing should always be discard after 24 hours. This is because of the risk for the bacterial growth.

You are receiving report from a nurse at another hospital who will be transferring a patient to your ICU. The patient has a Sengstaken-Blackmore Tube. Which of the following statement is incorrect about this tubing? A. It is a four-lumen gastric tube B. It is used in patient's with esophageal varices C. A NG tube is inserted in the opposite nare to collect secretions D. Scissors are kept at the beside at all times with this tubing type

A. It is a four-lumen gastric tube A Sengstaken-Blackemore tube is a THREE lumen tube. This tube has three different components: inflatable esophageal balloon, inflatable gastric balloon, and a gastric aspiration lumen. A Minnesota tube is a FOUR lumen tube that has an additional lumen for aspirating secretions that collect in the esophagopharyneal area.

You are caring for a patient with a nephrostomy tube. What nursing intervention would you include in your plan of care? A. Maintain patency of the tube B. Irrigate as prescribed by the MD using sterile water C. Clamp the tube every 6 hours for 1 hour intervals D. Keep tube in a vertical position at all times

A. Maintain patency of the tube Nephrostomy tubes should always be patent and if patency cannot be establish the MD should be notified immediately. As prescribed by the MD, the tube should be irrigate with sterile normal saline NOT water and the tube should NEVER be clamped.

A patient with a pneumothorax has a chest tube present. The water seal chamber has continuous bubbling. What intervention would you take? A. Notify the MD because there is a leak in the system. B. This is normal and expected because the patient has a pneumothorax. C. Increase the suction 2-5 mmHg until bubbling stops. D. None of the above are correct.

A. Notify the MD because there is a leak in the system. Intermittent bubbling is to be expected in a patient who has a pneumothorax in the water seal chamber BUT continuous bubbling is not normal. If continuous bubbling is noted the MD must be notified.

What are strategies to prevent Ventilator-associated Pneumonia? select all that apply A. Oral care every 4 hours B. HOB elevated 30-45 degrees unless contraindicated by the patient's condition C. HOB elevated 10-15 degrees, unless contraindicated by the patient's condition D. Allow family to suction patient as needed to remove secretions

A. Oral care Q4h B. HOB elevated 30-45 degrees unless contraindicated by patients condition.

Your outside the patient's room when you hear a "thud". You run into the room and the patient has fallen and the patient's chest tube was accidentally pulled out. You quickly do the following? A. Pinch the skin opening together, apply an occlusive sterile dressing, cover the dressing with 2 inch tape and notify the MD. B. Tell the patient to take a deep breath and hold it, apply a dry sterile dressing with petroleum gauze dressing with tape, and notify the MD C. Clamp the tubing, cover with a Kerlix and tape, and notify the MD D. Turn the patient on the affected side and call for help

A. Pinch the skin opening together, apply an occlusive sterile dressing, cover the dressing with 2 inch tape and notify the MD. If a chest tube is accidentally removed you should do the following: Pinch the skin opening together, apply an occlusive sterile dressing, cover the dressing with 2 inch tape and notify the MD. Telling the patient to take a deep breath and hold it, apply a dry sterile dressing with petroleum gauze dressing with tape, and notify the MD is what you do when the chest tube is removed by the MD. The other options are incorrect.

During the morning assessment of your patient with a chest tube, you note that there is no fluctuation in the water seal chamber. The patient does not appear to be in respiratory distress. What could have caused this ceasing of fluctuation? A. The lung may have re-expanded. B. The water in the seal chamber is inadequate. C. The collection chamber is full. D. The dry suction is turned on high.

A. The lung may have re-expanded. If fluctuation in the water seal chamber stops it could be the following: the tube is obstructed, suction is not working properly or the lung has re-expanded. In this case, the lung had re-expanded.

Your patient has an endotracheal tube. You are assessing placement by listening to the lung sounds and you notice that the breath sounds and chest wall movement are absent on the left side? What is usually the cause of this? A. The tube may be displaced in the right main stem bronchus B. A pneumothorax may be developing and a STAT chest x-ray should be ordered C. The incorrect size tubing was used D. The tube is not above the carina and must be re-inserted

A. The tube may be displaced in the right main stem bronchus If you are assessing placement of an endotracheal tube and notice that while manually ventilating with an Ambu bag the breath sounds and chest wall movement are absent on the left side, it may be because the tube has displaced in the right main stem bronchus. All other options are incorrect.

You are assessing your patient with an endotracheal tube and note that the patient is able to make verbal sounds. What is the most likely cause? A. There is a leak. B. There is an occlusion. C. The tube is displaced. D. None of the above. This is normal,

A. There is a leak. When conducting the minimal leak technique the patient should not be able to make verbal sounds or no air should be felt coming out of the patient's mouth. If the happens there is a leak. This sign is not present with the other selections.

Your patient has a chest tube. Your assessing the water seal chamber and you note that the water moves up as the patient inhales and then moves down when the patient exhales. What may be causing this to happen? A. This is normal and expected. B. The chest tube has a leak. C. The left chest tube is occluded. D. The water seal suction should be increased 2-5 mmHG.

A. This is normal and expected. This is a good sign and lets you know the water seal chamber is working correctly. If excessive bubbling was noted it would indicate an air leak in the chest tube system.

You are assisting a MD with the removal of a chest tube. What activity may the MD have the patient perform while the chest tube is being removed? A. Valsalva Maneuver B. Leopold Maneuver C. Chest Physiotherapy D. Huff Cough Techniqure

A. Valsalva Maneuver Depending on MD preference they may have the patient take a deep breath, exhale, and bear down which is known as the Valsalva's maneuver.

The low tidal volume alarm on a client's ventilator keeps sounding. What is the nurse's first action? A) Manually ventilate the client. B) Put air into the endotracheal tube cuff. C) Check ventilator connections. D) Call the physician.

Answer: C- Check ventilator connections Rationale: Ventilator connections should be check initially and loose connections or disconnections should be fixed. If there is no immediate problem found, the client should be manually ventilated and another person should check the ventilator connections. Test Plan: Management of care

A client has just been intubated for placement on a mechanical ventilator. What is the first assessment of the tube placement? A) Chest X-Ray B) Auscultation of breath sounds C) Pulse oximetry reading of 95% D) End tidal CO2 monitoring

Answer: D- End tidal CO2 monitoring Rationale: End tidal CO2 monitoring is the first intervention to determine if the endotracheal tube is in place, but a chest x-ray is still needed to confirm proper placement.

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 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

A patient with a chest tube has no fluctuation of water in the water seal chamber. What could be the cause of this? A. This is an expected finding. B. The lung may have re-expanded or there is a kink in the system. C. The system is broken and needs to be replaced. D. There is an air leak in the tubing.

B

The nurse is caring for four patients. Which patient should be assessed first? a. the patient with a pain rating of 7 out of 10 whose oxygenation saturation is 91% b. the patient with a respiratory rate of 28 and asymmetric chest wall movement c. the patient with bilateral crackles, fever, and mucopurulent sputum d. the patient who is in a tripod position and breathing through pursed lips

B

The pressure required in the pleural space to keep the lungs inflated is: A. Positive. B. Negative. C. Atmospheric. D. All of the above.

B

What type of chest tube system does this statement describe? This chest drainage system has no water column to control suction but uses a suction monitor bellow that balances the wall suction and you can adjust water suction pressure using the rotary suction dial on the side of the system. It allows for higher suction pressure levels, has no bubbling sounds, and water does not evaporate from it as with other systems. A. Mediastinal chest tube system B. Dry suction chest tube system C. Wet suction chest tube system D. Dry-Wet suction chest tube system

B

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

While helping a patient with a chest tube reposition in the bed, the chest tube becomes dislodged. What is your immediate nursing intervention? A. Stay with the patient and monitor their vital signs while another nurse notifies the physician. B. Place a sterile dressing over the site and tape it on three sides and notify the physician. C. Attempt to re-insert the tube. D. Keep the site open to air and notify the physician.

B

A patient is about to have their chest tube removed by the physician. As the nurse assisting with the removal, which of the following actions will you perform? Select-all-that-apply: A. Educate the patient how to take a deep breath out and inhale rapidly while the tube in being removed. B. Gather supplies needed which will include petroleum gauze dressing per physician preference. C. Place the patient in Semi-Fowler's position. D. Have the patient take a deep breath, exhale, and bear down during removal of the tube. E. Pre-medicate prior to removal as ordered by the physician. F. Place the patient is prone position after removal.

B, C, D, E

Your patient has a PEG tube and you are about to administer a feeding. While checking residual you obtain 95 ml of stomach contents. What would be your next nursing intervention? A. Hold the feeding and immediately notify the MD of the assessed amount of residual B. Administered the scheduled feeding C. Wait 30 minutes and reassess residual D. Skip this scheduled feeding and administer the next feeding due in 6 hours

B. Administered the scheduled feeding If stomach residual is less than 100 cc, the feeding should be administered. If there was more than 100 cc of residual, the feeding would be held and the MD would be notified for further orders.

A patient is receiving positive pressure mechanical ventilation and has a chest tube. When assessing the water seal chamber what do you expect to find? A. The water in the chamber will increase during inspiration and decrease during expiration. B. There will be continuous bubbling noted in the chamber. C. The water in the chamber will decrease during inspiration and increase during expiration. D. The water in the chamber will not move.

C

Clinical manifestations related to pneumothorax include the following except for: A. Pleuritic pain. B. Respiratory distress. C. Acrocyanosis. D. Tachypnea.

C

In regards to the patient in the question above, 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 an occlusive dressing over the chest wound and tape it on three sides D. Prepare the patient for a thoracentesis

C

When receiving report during the transfer of a patient who has a pneumothorax, the healthcare provider is told that the patient has subcutaneous emphysema. Which assessment finding will validate this statement? a. a grating sound auscultated over the mediastinum b. asymmetric chest wall expansion during inhalation c. a crackling sensation when the chest is palpated d.diminished breath sounds bilaterally

C

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

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

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

The client is on CPAP for weaning from a mechanical ventilator. Assessment reveals a respiratory rate of 32/min, oxygen saturation of 88 percent, and use of accessory muscles. What should the nurse anticipate will occur? A. The FiO2 will be increased. B. Weaning will continue. C. The client will be placed back on full ventilatory support. D. The client will be extubated.

Correct Answer: C. The client will be placed back on full ventilatory support. Rationale: Weaning should be discontinued, as the client is showing signs of intolerance.

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 who has a diagnosis of pneumonia reports a sudden onset of sharp pain on one side of the chest. The patient is dyspneic and oxygen saturation falls to 89\%89%89, percent. After administering oxygen to the patient, which of these actions should the healthcare provider perform next? a. assess the capillary refill b. take a full set of vital signs c. lower the head of the bed d. auscultate the lungs bilaterally

D

A patient who is attached to a chest tube drainage unit is being transported from the emergency department to the respiratory care unit. Which of these actions should be performed by the healthcare provider in preparation for the transport? a. stabilize the chest tube drainage unit on the patient's bed b. disconnect the chest tube unit during transportation c. clamp the chest tube with a padded hemostat d. secure the chest tube unit on the gurney

D

An initial characteristic symptom of a simple pneumothorax is: A. ARDS. B. Severe respiratory distress. C. Sudden onset of chest pain. D. Tachypnea and chest discomfort.

D

The following are types of pneumothorax except: A. Trauma. B. Simple. C. Tension. D. Direct.

D

The patient in room 2569 calls on the call light to tell you something is wrong with his chest tube. When you arrive to the room you note that the drainage system has fallen on its side and is leaking drainage onto the floor from a 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

Which of the following should the nurse assess in a patient with pneumothorax? A. Tracheal alignment. B. Expansion of the chest. C. Breath sounds. D. All of the above.

D

You are providing care to a patient with a chest tube. On assessment of the drainage system, you note continuous bubbling in the water seal chamber and oscillation. Which of the following is the CORRECT nursing intervention for this type of finding? A. Reposition the patient because the tubing is kinked. B. Continue to monitor the drainage system. C. Increase the suction to the drainage system until the bubbling stops D. Check the drainage system for an air leak.

D

A Client has been intubated and placed on a volume-cycled mechanical ventilator. The nurse carefully assess the client for findings associated with a risk associated with this type of ventilator. What is the risk? A. Hypoventilation B. Hypercapnia C. Respiratory acidosis D. Barotrauma

D. Barotrauma rationale: the volume-cycled ventilator has the potential to increase pressure in order to deliver the set volume. barotrauma is a risk associated with this form of mechanical ventilation.