ATI closed-chest pretest
A nurse is assessing a client 5 hours after insertion of a chest tube that is attached to a water-seal drainage system. Which of the following observations about the drainage should the nurse report to the provider?
1. 400 mL drainage since insertion. 2. A gush of fluid when repositioning the patient *3. About 150 mL/hr drainage over the past 2 hours. After the first few hours, the nurse should report drainage that exceeds 70 mL/hr. Clients who lose 100 mL of blood every 15 min might require autotransfusion within 6 hr. 4. Significant decrease in drainage in the past 3 hours.
A nurse is caring for a client who requires a chest tube. The provider asks for the suction pressure of the closed-chest drainage system to be set at -40 cm of water. Which of the following closed-chest drainage systems should the nurse prepare for this client?
1. Pneumostat 2. Water-seal system 3. Heimlich valve *4. 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 clients 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 preparing to transport a client who has a chest tube and a closed-chest wet-suction drainage system to radiology. Which of the following actions should the nurse take when detaching the suction source for transportation?
1. clamp the chest tube. 2. Milk the chest tube *3. 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. 4. Empty the collection chamber.
A nurse is caring for a client who has a chest tube in place. Which of the following strategies should the nurse use to help promote comfort for the client?
*1. Have the client splint the affected side during coughing* It is essential for a client with a chest tube to cough to prevent postoperative complications and 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. 2. Perform passive range-of-motion exercises 3. Place the client in a supine position with minimal elevation 4. Encourage ambulation
A nurse is planning education for a client who has a chest tube in place that is attached to a closed-chest drainage system. Which of the following instructions should the nurse plan to provide when the client is ready to ambulate?
*1. keep the collection device upright at all times* The closed-chest drainage system must be kept upright at all times to ensure that the tubing drains optimally and the system functions correctly. 2. Disconnect the system when showering. 3. Keep the collection deice at chest level at all times. 4. Allow the tubing to hang in a dependent loop when ambulating.
A nurse is caring for a client who is 6 hours post operative and has a chest tube in place that is attached to a closed-chest water-seal drainage system. The nurse should identify that which of the following is an indication of a problem in the drainage system?
1. Constant bubbling in the suction-control chamber. 2. Fluctuations in the fluid level in the water seal chamber 3. Occasional bubbling in the water seal chamber. *4. 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 near the site of the chest tube insertion.
A nurse is caring for a client who has a chest tube in place that is attached to a water-seal drainage system. Which of the following findings should the nurse recognize as an indication of subcutaneous emphysema?
1. Diminished lung sounds on the affected side *2. A dry, crackling sound at the insertion site when pulled* A dry, crackling sound at the insertion site is an indication of subcutaneous emphysema, which is a result of air leaking into the subcutaneous tissue surrounding the chest-tube insertion site. 3. Absence of drainage in the collection chamber 4. hyperresonance when percussing the affected lung
A nurse is caring for a client who has a chest tube in place that is attached to a closed-chest drainage system. Which of the following actions should the nurse take if the chest tube becomes dislodged from the closed chest drainage system?
1. Instruct the client to inhale deeply *2. 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 client inhales. 3. Gently milk the chest tube in a proximal-to-distal direction 4. Tape sterile gauze around the open end of the chest tube.
