Chest trauma and tubes Davis
The health-care provider has ordered a continuous intravenous infusion of aminophylline. The client weighs 165 pounds. The infusion order is 0.3 mg/kg/hr. The bag is mixed with 500 mg of aminophylline in 250 mL of D5W. What rate should the nurse set the pump?
11 mL/hr First, convert pounds to kilograms 165 pounds ÷ 2.2 = 75 kg Then, determine how many milligrams of aminophylline per hour should be administered: 0.3 mg × 75 kg = 22.5 mg/hour Then, determine how much aminophylline is delivered per liter: 500 mg ÷ 250 mL = 2 mg/1 mL If 2 mg/1 mL is delivered, then to deliver the prescribed 22.5 mg/hour, the rate must be set at 22.5 ÷ 2 = 11.25 mL/hr
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 fluctuation (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
ANS 1 1. Assessment of the lung sounds could indicate that the client's lung has reexpanded because it has been three (3) days since the chest tube has been inserted. 2. This should be done to ensure that the lung has reexpanded, but it is not the first intervention. 3. The HCP will need to be notified so that the chest tube can be removed, but it is not the first intervention. 4. This situation needs to be documented, but it is not the first intervention. TEST-TAKING HINT:When the stem asks the test taker to identify the first intervention, all four (4) answer options could be interventions that are appropriate for the situation, but only one (1) is the first intervention. Remember to apply the nursing process: the first step is assessment
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.
ANS 1 1. Checking to see if someone has increased the suction rate is the simplest action for the nurse to implement; if it is not on high, then the nurse must check to see if the problem is with the client or the system. 2. No fluctuation (tidaling) would cause the nurse to assess the tubing for a blood clot. 3. The tube is milked to help dislodge a blood clot that may be blocking the chest tube causing no fluctuation (tidaling) in the waterseal compartment. The chest tube is never stripped, which creates a negative air pressure and would suck lung tissue into the chest tube. 4. Encouraging the client to cough forcefully will help dislodge a blood clot that may be blocking the chest tube, causing no fluctuation (tidaling) in the water-seal compartment. TEST-TAKING HINT: The test taker should always think about assessing the client if there is a problem and the client is not in immediate danger. This would cause the test taker to eliminate options "3" and "4." If the test taker thinks about bubbling, he or she should know it has to do with suctioning.
Which intervention should the nurse implement for a male client who has had a leftsided 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.
ANS 1 1. The client must take deep breaths to help push the air out of the pleural space into the water-seal drainage, and deep breaths will help prevent the client from developing pneumonia or atelectasis. 2. The client must take deep breaths; shallow breaths could lead to complications. 3. Deep breaths must be taken to prevent complications. 4. This is a cruel intervention; the nurse can medicate the client and then encourage deep breathing. TEST-TAKING HINT: If the test taker reads options "2" and "3" and notices that both reflect the same idea—namely, that deep breaths are not necessary—then both can either be eliminated as incorrect answers or kept as possible correct answers. Option "4" should be eliminated based on being a very rude and threatening comment.
The nurse is caring for a client diagnosed with a pneumothorax who had chest tubes inserted four (4) hours ago. There is no fluctuating (tidaling) in the water-seal compartment of the closed chest drainage system. Which action should the nurse take first? 1. Milk the chest tube. 2. Check the tubing for kinks. 3. Instruct the client to cough. 4. Assess the insertion site.
ANS 2 . 1. No fluctuation in the water-seal chamber four (4) hours post-insertion indicates the tubing is blocked; the nurse can milk the chest tube, but it is not the first action. 2. The nurse should implement the easiest intervention first. The nurse should check to see if the tubing is kinked, causing a blockage between the pleural space and the water-seal bottle. 3. Coughing may help push the clot in the tubing into the drainage bottle, but the first intervention is to check and see if the client is lying on the tubing or the tube is kinked somewhere. 4. The insertion site can be assessed, but it will not help determine why there is no fluctuation in the water-seal drainage compartment.
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
ANS 2 1. Keeping the drainage system lower than the chest promotes drainage and prevents reflux. 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. 3. Ambulation facilitates lung ventilation and expansion; drainage systems are portable to allow ambulation while chest tubes are in place. 4. The client should ambulate, but getting up and using the bedside commode is better than staying in the bed, so no action would be needed. TEST-TAKING HINT: "Warrants immediate intervention" means the test taker must identify the situation in which the nurse should intervene and correct the action, demonstrate a skill, or somehow intervene with the unlicensed assistant's behavior.
The client is admitted to the emergency department with chest trauma. When assessing 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.
ANS 2 1. The client with pneumothorax would have absent breath sounds and tachypnea. 2. Unequal lung expansion and dyspnea would indicate a pneumothorax. 3. Consolidation occurs when there is no air moving through the alveoli as in pneumonia; frothy sputum occurs with congestive heart failure. 4. Barrel chest and polycythemia are signs of chronic obstructive pulmonary disease. TEST-TAKING HINT: The test taker can use "chest trauma" or "pneumothorax" to help select the correct answer. Both of these words should cause the test taker to select "2" because unequal chest expansion would result from trauma.
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.
ANS 2 1. The nurse should gather a thoracotomy tray and the chest tube drainage system and take it to the client's bedside, but it is not the first intervention. 2. The insertion of a chest tube is an invasive procedure and so requires informed consent. Without a consent form, this procedure cannot be done on an alert and oriented client. 3. This is a correct position to place the client for a chest tube insertion, but it is not the first intervention. 4. The physician will discuss the procedure with the client, then informed consent must be obtained, and then the nurse can do further teaching. TEST-TAKING HINT: The test taker must know that invasive procedures require informed consent and legally it must be obtained first before anyone can touch the client.
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.
ANS 2 1. This is an expected finding in the suction compartment of the drainage system that indicates adequate suctioning is being applied. 2. At three (3) days post-insertion, no fluctuation (tidaling) indicates the lung has reexpanded, which indicates the treatment has been effective. 3. Blood in the drainage bottle is expected for a hemothorax but does not indicate the chest tubes have reexpanded the lung. 4. Taking a deep breath without pain is good, but it does not mean the lungs have reexpanded. TEST-TAKING HINT: The test taker must be knowledgeable about chest tubes to be able to answer this question. The test taker must know the normal time frame and what is expected for each compartment of the chest tube drainage system
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.
ANS 3 . 1. This is incorrect information. It is the description of a spontaneous pneumothorax. 2. This is the description of an open pneumothorax. 3. This describes a tension pneumothorax. It is a medical emergency requiring immediate intervention to preserve life. 4. This is called an iatrogenic pneumothorax which also may be caused by thoracentesis or lung biopsy. A tension pneumothorax could occur from this procedure, but it does not describe a tension neumothorax. TEST-TAKING HINT: The test taker must always be clear about what the question is asking before answering the question. If the test taker can eliminate options "1" and "2" and can't decide between "3" and "4," the test taker must go back to the stem and clarify what the question is asking.
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.
ANS 3 1. A STAT chest x-ray would not be needed to determine why there is no fluctuation in the water-seal compartment. 2. Increasing the amount of wall suction does not address why there is no fluctuation in the water-seal compartment. 3. The key to the answer is "2 hours." The air from the pleural space is not able to get to the water-seal compartment, and the nurse should try to determine why. Usually the client is lying on the tube, it is kinked, or there is a dependent loop. 4. The stem does not state that the client is in respiratory distress, and a pulse oximeter reading detects hypoxemia but does not address any fluctuation in the water-seal compartment. TEST-TAKING HINT: The test taker should apply the nursing process to answer the question correctly. The first step in the nursing process is assessment and "check" (option "3") is a word that can be used synonymously for assess. Monitoring (option "4") is also assessing, but the test taker should not check a diagnostic test result before caring for the client.
The client has a right-sided chest tube. As the client is getting out of the bed it is accidentally 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.
ANS 4 1. The health-care provider will have to be notified, but this is not the first intervention. Air must be prevented from entering the pleural space from the outside atmosphere. 2. The client should breathe regularly or take deep breaths until the tubes are reinserted. 3. The nurse must take action and prevent air from entering the pleural space. 4. Taping on three sides prevents the development of a tension pneumothorax by inhibiting air from entering the wound during inhalation but allowing it to escape during exhalation. TEST-TAKING HINT: The word "first intervention" in the stem of the question indicates to the test taker that possibly more than one (1) intervention could be indicated in the situation but only one (1) is implemented first. Remember, do not select assessment first without reading the question. If the client is in any type of crisis, then the nurse should first do something to help the client's situation.
The charge nurse is making client assignments on a medical floor. Which client should the charge nurse assign to the LPN? 1. The client with pneumonia who has a pulse oximeter reading of 91%. 2. The client with a hemothorax who has Hgb of 9 mg/dL and Hct of 20%. 3. The client with chest tubes who has jugular vein distention and BP of 96/60. 4. The client who is two (2) hours post-bronchoscopy procedure.
ANS 4 1. This pulse oximeter reading indicates the client is hypoxic and therefore is not stable and should be assigned to an RN. 2. This H&H are very low; therefore the client is not stable and should be assigned to an RN. 3. Jugular vein distention and hypotension are signs of a tension pneumothorax, which is a medical emergency, and the client should be assigned to an RN. 4. A client that is two (2) hours postbronchoscopy procedure could safely be assigned to an LPN. TEST-TAKING HINT: The test taker must understand that the LPN should be assigned the least critical client or the client that is stable and not exhibiting any complications secondary to the admitting disease or condition.
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.
ANS. 1, 4 ,5 1. The client should be in a high-Fowler's position to facilitate lung expansion. 2. The system must be patent and intact to function properly. 3. The client can have bathroom privileges, and ambulation facilitates lung ventilation and expansion. 4. Looping the tubing prevents direct pressure on the chest tube itself and keeps tubing off the floor, addressing both a safety and an infection control issue. 5. Subcutaneous emphysema is air under the skin, which is a common occurrence at the chest tube insertion site. TEST-TAKING HINT: The test taker should be careful with adjectives. In option "1" the word "low" makes it incorrect; in option "3," the word "strict" makes this option incorrect.
A nurse is caring for a client following a coronary artery bypass graft. Which assessment finding in the immediate postoperative period should be most concerning to the nurse? 1. No chest tube output for 1 hour when previously it was copious 2. Client temperature of 99.1°F (37.2°C) 3. Arterial blood gas (ABG) results show pH 7.32; Pco2 48; HCO3 28; Po2 80 4. Urine output of 160 mL in the last 4 hours
ANSWER: 1 A copiously draining chest tube that is no longer draining indicates an obstruction. There is an increased risk for cardiac tamponade or pleural effusion. A slight elevation in temperature could be the effects of rewarming after surgery. This should continue to be monitored, but is not immediately concerning. The ABG results show compensated respiratory acidosis. Though the pH is low and the PCO2 is high, the kidneys are compensating by conserving bicarbonate (HCO3). Normal pH is 7.35-7.45, CO2 32-42 mm Hg, HCO3 20-24 mmol/L, and Po2 75-100 mm Hg. A urine output of 160 mL/4 hr is equivalent to 40 mL/hr; adequate, but it warrants continued monitoring. Less than 30 mL/hr indicates decreased renal function.
A nurse is taking the health and social history of an adolescent client experiencing episodes of palpitations. Which components of the social history could contribute to the palpitations? SELECT ALL THAT APPLY. 1. Alcohol intake 2. Sexual history 3. Nicotine use 4. Caffeine intake 5. A sports injury to the chest
ANSWER: 1, 3, 4, 5 Alcohol, nicotine, and caffeine could contribute to the palpitations. Nicotine and caffeine are stimulants that increase the heart rate. Although alcohol is a depressant, it has been shown to be linked with supraventricular tachycardia (SVT) and heart palpitations because it irritates the cardiac muscle. Chest trauma during a sports event can induce dysrhythmias. A sexual history is an important part of the social history, although it does not likely contribute to the client experiencing palpitations. Test-taking Tip: Use knowledge of the physical effects of alcohol, nicotine, caffeine, and trauma. Use the process of elimination to select the correct options.
A nurse is caring for a client with a left-sided chest tube attached to a wet suction chest tube system.Which observation by the nurse would require immediate intervention? 1. Bubbling in the suction chamber 2. Dependent loop hanging off the edge of the bed 3. Banded connections between tubing sections 4. Occlusive dressing over chest tube insertion site
ANSWER: 2 A dependent loop creates pressure back up and prevents fluid from draining; this requires immediate intervention to prevent lung collapse. Bubbling in a wet suction chest tube system indicates that the suction is working and is an expected finding as are banded connections between sections of tubing. An occlusive dressing helps to prevent air from leaking into the subcutaneous space and maintains integrity of the closed drainage system. Test-taking Tip: Visualize the different parts of a chest tube system and consider which of the options do not fit or seem negative.
Following a normal chest x-ray for a client who had cardiac surgery, a nurse receives an order to remove the chest tubes. Which intervention should the nurse plan to implement first? 1. Auscultate the client's lung sounds 2. Administer 4 mg morphine sulfate intravenously 3. Turn off the suction to the chest drainage system 4. Prepare the dressing supplies at the client's bedside
ANSWER: 2 Because the peak action of morphine sulfate is 10 to 15 minutes, this should be administered first.Auscultating the client's lungs before and after the procedure, turning off the suction, and assembling the dressing supplies are all necessary, but administering the analgesic should be first.
A client has a peripheral intravenous (IV) line with a piggyback line, oxygen at 2 liters per nasal cannula, an as needed (prn) nebulizer treatment, and a chest tube connected to a chest drainage system. Several family members are present, wanting to be very helpful, and have been placing the oxygen back on when the nasal cannula slips, turning the IV pump off when it alarms, and placing the nebulizer tubing in the mouthpiece of the nebulizer. Which action by the nurse is required for the safe care of the client? 1. Inform the family that they are not allowed to touch any medical equipment 2. Inform the family that they must get help from clinical staff when there is a need to connect tubing or devices 3. Thank the family for noticing when tubing is disconnected and getting the client the treatment required 4. Inform the family that they are only allowed to turn off the IV pump alarm
ANSWER: 2 The nurse should inform nonclinical staff, clients, and their families that they must get help from clinical staff whenever there is a real or perceived need to connect or disconnect devices or infusions. The family may touch the equipment; however, they should not operate any client care equipment including answering alarms and reconnecting tubing. The potential for incorrect reconnection exists. Tubing misconnections have resulted in death. Test-taking Tip: Apply knowledge of safety policies and guidelines. Note that only option 2 informs the family of the actions to take for tubing disconnections or devices that are alarming.
. A nurse is caring for a client in an emergency department who has five fractured ribs from blunt chest trauma. The client is rating pain at 9 out of 10 on a 0 to 10 numeric scale. For which pain management modality should the nurse advocate? 1. NSAIDs 2. Oral analgesics (narcotic + acetaminophen) 3. Regional/local analgesia (epidural or intercostal injection) 4. Intravenous (IV) bolus meperidine (Demerol®)
ANSWER: 3 Epidural analgesics and intercostal nerve blocks are the most optimal modality for blunt chest trauma because they directly target the injury site. Oral analgesics generally are not adequate to manage the pain associated with rib fractures. Meperidine is not the ideal narcotic for managing this type of pain because of its multiple adverse side effects. Test-taking Tip: Consider the physiological implications of the injury in selecting the best option and the most directed type of intervention.
A nurse checks on a client following lower lobectomy for lung cancer. The nurse finds that the client is dyspneic with respirations in the 40s, is hypotensive, has a SaO2 at 86% on 10 L close-fitting oxygen mask, has a trachea that is deviated slightly to the left, and notes that the right side of chest is not expanding. Which action should be taken by the nurse first? 1. Notify the physician 2. Give the client whatever medication was ordered to decrease anxiety 3. Check the chest tube to make sure it is not obstructed 4. Turn up the oxygen liter flow
ANSWER: 3 The scenario presented implies that the client is suffering from a tension pneumothorax as a result of a kinking of the tubing or other blockage in the chest tube system. Although notifying the physician would be warranted, unkinking tubing would give some immediate relief and would be the best initial action.Neither turning up the oxygen flow nor treating the client for anxiety would correct this problem.
Following an unrestrained motor vehicle crash, a client presents to an emergency department with multiple injuries, including chest trauma. A physician notifies the care team that the client has progressed to acute respiratory distress syndrome (ARDS) and requests that the family be updated on the client's condition. The nurse should plan to discuss with the family that: 1. the condition generally stabilizes with positive prognosis. 2. the client can be discharged with home oxygen. 3. the condition is always fatal. 4. the condition is highly life-threatening and that end-of-life concerns should be addressed.
ANSWER: 4 ARDS has a reported mortality rate of 50% to 70% and family should be prepared for the possibility that their loved one may not survive the injury or diagnosis. The nurse must be able to discuss the care to be given, the progression of the syndrome, and make appropriate referrals as needed (such as pastoral care). The condition often does not have a positive prognosis and, if the client survives, home oxygen may or may not be needed. ARDS is not always fatal.
