Chest Trauma NCLEX
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.
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 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.
Which of these individuals is at risk for a primary spontaneous pneumothorax?
6 ft. 138 lb pt. who smokes A primary spontaneous pneumothorax occurs most commonly in young males who are tall and thin.
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 crackling sensation when the chest is palpated If air leaks into the subcutaneous tissue, a crackling or popping sensation can be felt on palpation.
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?
Encourage the patient to breathe deeply and cough regularly. Regular deep breathing and coughing will help re-expand the collapsed lung.
The healthcare provider enters the room of a patient with a diagnosis of tuberculosis and finds the patient dyspneic. The neck veins are also visibly distended. Which of these additional assessments should the healthcare provider perform immediately?
Palpate for tracheal deviation Pressure will eventually build up causing a shift of the mediastinal structures from midline.
The healthcare provider is caring for four patients. Which patient should be assessed first?
RR 28 asymmetrical chest movement Tachypnea and asymmetric chest wall movement are signs of a pneumothorax, so this patient needs prompt assessment and intervention.
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?
Secure the chest tube unit on the gurney. The chest tube drainage unit must always be kept below the patient's chest level to facilitate drainage and avoid backward flow of pleural drainage.
The healthcare provider is assisting during the insertion of a pulmonary artery catheter. Which of these, if assessed in the patient, would indicate the patient is experiencing a complication from the catheter insertion?
Tracheal deviation from midline
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.
3. At three (3) days post-insertion, no fluctuation (tidaling) indicates the lung has reexpanded, which indicates the treatment has been effective.
The nurse observes air bubbles in a patient's chest tube water seal chamber. How should the nurse interpret this finding? 1. normal 2. an emergency 3. an indication that the pneumothorax is worsening 4. an indication to remove the chest tube
1. Global Rationale: Periodic air bubbles in the water-seal chamber are normal and indicate that trapped air is being removed from the chest. This is not an emergency situation, or one that indicates a worsening condition. The nurse would need a physician's order to remove a chest tube. The patient still needs the chest tube in place.
During the assessment of a patient's respiratory status, the nurse notes paradoxical lung movements. This finding is consistent with what health problem? 1. flail chest 2. pleurisy 3. pneumothorax 4. pneumonia
1. Global Rationale: Physiologic function of the chest wall is impaired as the flail segment is sucked inward during inhalation and moves outward with exhalation. This is known as paradoxic movement. This movement is not associated with pleurisy, pneumothorax, or pneumonia.
A 20-year-old patient who is asking questions about smoking cessation tells the nurse about an upcoming class on scuba diving. The nurse recognizes that this patient might be at risk for developing what health problem? 1. pleural effusion 2. pleurisy 3. pneumothorax 4. hemothorax
3. Global Rationale: Primary pneumothorax affects previously healthy people, usually tall, slender men between ages 16 and 24. The cause of primary pneumothorax is unknown. Risk factors include smoking. Certain activities also increase the risk of spontaneous pneumothorax, such as high-altitude flying and rapid decompression during scuba diving. The patient's age, smoking status, and scuba diving interest do not increase the risk for developing a pleural effusion, pleurisy, or a hemothorax.
The nurse is caring for a client with a right-sided chest tube secondary to a pneu- mothorax. 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.
***2. The system must be patent and intact to function properly. ***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.
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 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.
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.
The nurse is caring for a patient on mechanical ventilation with positive end expiratory pressure (PEEP). When assessing the patient, which finding would indicate the possibility of tension pneumothorax? 1. new onset of absent breath sounds over the right lung 2. blood pressure of 170/80 3. pulse oximetry readings ranging from 94% to 96% 4. crackles and wheezing heard in both lungs
1. Global Rationale: In a tension pneumothorax, air enters the pleural space with each breath but does not exit. Progressive accumulation of air in the pleural space leads to collapse of the lung on the affected side and hypoxia. As a result, the patient would have absent breath sounds on the affected side rather than adventitious sounds (crackles and wheezes). As the pressure in the thorax increases, cardiac output declines and the patient becomes hypotensive. A pulse oximetry reading of 94% demonstrates adequate oxygenation.
A patient has a chest tube inserted for a pneumothorax. What should the nurse expect when assessing the drainage system? 1. periodic bubbling in the water seal chamber immediately after insertion 2. no evidence of tidaling 3. vigorous bubbling in the suction control chamber 4. large amount of bloody drainage in the drainage collection chamber
1. Global Rationale: When a chest tube is inserted in the pleural space for a pneumothorax, the trapped air is allowed to escape and periodic bubbling is observed in the water seal as the lung reexpands. The water column in the water seal should rise with inspiration and fall with expiration (tidaling). There should be gentle bubbling in the suction control chamber to avoid rapid evaporation of the fluid in the chamber. Large amounts of bloody drainage would be anticipated after chest tube insertion for hemothorax.
The nurse is assessing a patient recovering from a motor vehicle crash. Which assessment finding indicates that the patient is experiencing a pneumothorax? 1. hyperresonance to percussion at the apex of the left lung 2. dullness to percussion at the base of the left lung 3. crackles throughout the left lung 4. shallow breathing
1. Global Rationale: In pneumothorax, the percussion tone is hyperresonant due to the trapped air in the pleural space. Dullness to percussion is suggestive of fluid accumulation, such as in hemothorax. Crackles in the left lung suggest fluid accumulation in the alveoli. Shallow breathing can occur but is not specific to pneumothorax. It would also be seen in rib fractures and flail chest.
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.
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 con- sent. 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.
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.
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 post- bronchoscopy procedure could safely be assigned to an LPN. TEST-TAKING HINT: The test taker must under- stand that the LPN should be assigned the least critical client or the client that is stable and not exhibiting any complications second- ary to the admitting disease or condition.
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.
3.
A patient is diagnosed with a tension pneumothorax. What should the nurse expect to assess in this patient? Standard Text: Select all that apply. 1. hypertension 2. distended neck veins 3. bradycardia 4. absent breath sounds on the affected side 5. tracheal deviation toward unaffected side
2, 4, 5 Global Rationale: Manifestations of a tension pneumothorax include hypotension, shock, distended neck veins, severe dyspnea, tachypnea, tachycardia, decreased respiratory excursion, absent breath sounds on affected side, and tracheal deviation toward unaffected side.
A patient has undergone open heart surgery for a congenital heart defect and has a chest tube drainage system in place. If there is damage to the thoracic duct during the procedure, what type of fluid will the healthcare provider observe in the collection chamber?
milky white The thoracic duct is a major lymphatic vessel.
Nurse Oliver observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?
there is an air leak. Constant bubbling in the chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.
The student nurse is learning how to care for patients who had thoracic surgery following a diagnosis of lung cancer. The intensive care unit nurse is assessing the student's understanding. Which statements by the student indicate the need for further education? Standard Text: Select all that apply. 1. "I should assess the patient's respiratory system at least every four hours." 2. "I really shouldn't even offer narcotic pain medications to this patient because it will result in severe respiratory depression." 3. "If there are items that the patient needs frequently, I should keep them across the hospital room. This will ensure that the patient will get better faster." 4. "The patient's head of bed should be maintained between 15 and 30 degrees." 5. "The area between the visceral and parietal pleura must be filled with positive pressure to work appropriately, and this can be accomplished with a functioning chest tube."
2, 3, 4, 5 Global Rationale: Narcotic pain medications should be offered after thoracic surgery to ensure that the patient can perform pulmonary rehabilitation exercises such as coughing, deep breathing, and incentive spirometry. The patient who is using narcotic pain medications to achieve pain control must be monitored for respiratory depression so that it can be treated. This patient should be encouraged to conserve energy. Items that are used frequently should be kept within the patient's reach. The nurse should elevate the head of the bed to 60 degrees, because elevating the head of the bed reduces pressure on the diaphragm and permits optimal lung expansion. The area between the visceral and parietal pleura must be filled with negative pressure to work appropriately. The chest tube is used to achieve negative pressure within this space. The nurse should perform a respiratory assessment at least every four hours.
The client has a right-sided chest tube. As the client is getting out of the bed it is acci- dentally 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.
4.
The healthcare provider is caring for a patient who has a pneumothorax. When assessing the patient and the chest tube drainage system, a large fibrin clot is noted in the tubing. Which additional assessment finding requires immediate action by the healthcare provider?
A downward trend in blood pressure Clots in the system can cause occlusion and lead to a tension pneumothorax, which may be evidenced by a downward trend in blood pressure as increased pressure on the heart and great vessels impair cardiac output.
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%, percent. After administering oxygen to the patient, which of these actions should the healthcare provider perform next?
Auscultate the lungs bilaterally If breath sounds are distant or absent on one side, the healthcare provider will suspect a pneumothorax.