Chest Tube ATI
A nurse is caring for a client who is scheduled to have his chest tube removed. Which of the following actions should the nurse take? A. Cover the insertion site with a hydrocolloid dressing after removal B. Provide pain medication immediately after removal C. Instruct the client to perform the Valsalva maneuver during removal D. Delegate removal of the chest tube to a licensed practical nurse (LPN)
Correct Answer: C. Instruct the client to perform the Valsalva maneuver during removal The nurse should instruct the client to perform the Valsalva maneuver during removal to maintain the appropriate amount of negative pressure in the chest in order to prevent air entry into the pleural space.
A nurse on a medical-surgical unit is caring for 4 clients. Which of the following clients should the nurse monitor for crepitus? A. A client who has a chest tube following a pneumothorax B. A client who has an acute exacerbation of Crohn's disease C. A client who is postoperative following a laparoscopic appendectomy D. A client who is recovering from thyroid storm
Correct Answer: A. A client who has a chest tube following a pneumothorax Crepitus, a crackling sound resulting from air trapped under the skin, can be palpated following a pneumothorax. The nurse should report this finding to the provider.
A community health nurse is performing client triage while participating in a disaster drill. The nurse should recommend that which of the following client injuries receives treatment first? A. Hemothorax B. Open humeral fracture C. Multiple deep abrasions on the arms and face D. Superficial partial-thickness burns on both legs Check Answer Question Feedback Show Explanation Grade Pause Previous
Correct Answer: A. Hemothorax The nurse should apply the survival potential priority-setting framework in mass casualty situations, when resources are scarce and resources must be allocated to save the greatest number of lives. While it could seem that the client who is most at risk should receive priority care, this client is the lowest priority. The nurse should assign the highest priority to the client with injuries that are severe who has the potential to survive with treatment. Therefore, the nurse should recommend that the client who has a hemothorax receives treatment first. A hemothorax is life-threatening, but with chest-tube insertion and stabilization, the client is likely to survive.
A nurse is caring for a client who has a pelvic fracture. The client reports sudden shortness of breath, stabbing chest pain, and feelings of doom. This client is experiencing which of the following complications? A. Pneumonia B. Pulmonary embolus C. Tension pneumothorax D. Tuberculosis
Correct Answer: B. Pulmonary embolus Immobility following musculoskeletal trauma places the client at an increased risk of pulmonary embolus. The client might also exhibit tachycardia and chest petechiae and have a decreased SaO2. The nurse should notify the rapid response team immediately.
A nurse is caring for a client who is postoperative following a thoracic lobectomy. The client has 2 chest tubes in place: 1 in the lower portion of the thorax and the other higher on the chest wall. When a family member asks why the client has 2 chest tubes, which of the following responses should the nurse make? A. "Two tubes were necessary due to excessive bleeding from the area of the surgery." B. "The tubes drain blood from 2 different lung areas." C. "The lower tube will drain blood, and the higher tube will remove air." D. "The second tube will take over if blood clots block the first tube."
Correct Answer: C. "The lower tube will drain blood, and the higher tube will remove air." The tube that is lower on the thorax will drain blood, and the tube that is higher on the thorax will allow for removal of air.
A nurse is planning care for a client following placement of a chest tube 1 hr ago. Which of the following actions should the nurse include in the plan of care? A. Clamp the chest tube if there is continuous bubbling in the water seal chamber B. Keep the chest tube drainage system at the level of the right atrium C. Tape all connections between the chest tube and drainage system D. Empty the collection chamber and record the amount of drainage every 8 hr
Correct Answer: C. Tape all connections between the chest tube and drainage system The nurse should tape all connections to ensure that the system is airtight and prevent the chest tubing from accidentally disconnecting.
A client comes to the emergency department in severe respiratory distress following left-sided blunt chest trauma. The nurse notes absent breath sounds on the client's left side and a tracheal shift to the right. For which of the following procedures should the nurse prepare the client? A. Tracheostomy placement B. Thoracentesis C. CT scan of the chest D. Chest tube insertion
Correct Answer: D. Chest tube insertion The client's manifestations indicate pneumothorax due to blunt chest trauma. The nurse should prepare for the provider to insert a chest tube and connect it to a water-seal drainage system.
A nurse is providing postoperative care for a client who has 2 chest tubes in place following a lobectomy. The client asks the nurse the reason for having 2 chest tubes. The nurse should inform the client that the lower chest tube is placed for which of the following reasons? A. Removing air from the pleural space B. Creating access for irrigating the chest cavity C. Evacuating secretions from the bronchioles and alveoli D. Draining blood and fluid from the pleural space
Correct Answer: D. Draining blood and fluid from the pleural space The nurse should inform the client that blood and fluids tend to accumulate in the bases and posterior areas of the pleural cavity following a lobectomy. For this reason, the lower chest tube primarily drains blood and fluid from the pleural space.
A nurse is caring for a client who has a chest tube. The nurse notes that the chest tube has become disconnected from the chest drainage system. Which of the following actions should the nurse take? A. Place the drainage system at the head of the client's bed B. Increase the suction to the chest drainage system C. Place the client on low-flow oxygen via nasal cannula D. Immerse the end of the chest tube in a bottle of sterile water
Correct Answer: D. Immerse the end of the chest tube in a bottle of sterile water If the chest tube and drainage system have become disconnected, air can enter the pleural space, producing a pneumothorax that can result in severe respiratory distress. To prevent a pneumothorax from developing, a temporary water seal can be established by immersing the end of the chest tube in an open bottle of sterile water. This allows air to escape and not enter the pleural space. A bottle of sterile water should always be readily available at the bedside for a client who has a chest tube.
A nurse is providing preoperative teaching to a client who has lung cancer and will undergo a pneumonectomy. Which of the following statements should the nurse include? (Select all that apply.) A. "You will have a chest tube in place after surgery." B. "We'll frequently help you turn, cough, and breathe deeply after surgery." C. "You will have to remain in bed for about 2 days after the surgery." D. "We'll give you oxygen to support your breathing if you need it." E. "You should expect pain for the first few days after surgery." Check Answer Question Feedback Show Explanation Grade Pause Previous
Correct Answers: A. "You will have a chest tube in place after surgery." B. "We'll frequently help you turn, cough, and breathe deeply after surgery." D. "We'll give you oxygen to support your breathing if you need it."
A nurse is caring for a client following a right pleural thoracentesis. The nurse measures a total of 35 mL of purulent drainage. Which of the following findings should the nurse recognize as an indication of a tension pneumothorax? (Select all that apply.) A. Tracheal deviation to the left B. Temperature of 38.8°C (102°F) C. Absent breath sounds on the right side D. Neck vein distention E. Bradypnea
Correct Answers: A. Tracheal deviation to the left C. Absent breath sounds on the right side D. Neck vein distention A tension pneumothorax can occur following a thoracentesis. A trachea that is deviated to the unaffected side instead of being in the center of the neck is a manifestation of a pneumothorax. Absent breath sounds on the affected side and neck vein distention are also manifestations of a pneumothorax. As the client's difficulty breathing increases, the blood flow return compresses, causing the neck veins to distend.
