Chest tubes and acid base balance
The nurse is preparing to obtain an arterial blood gas (ABG) sample on a client. Which action should the nurse first take? 1) Perform an Allen's test 2) placed a rolled towel under the client's wrist 3) clean the puncture site with an alcohol or povidone-iodine pad 4) palpate the artery with the index and middle fingers of one hand
1) Perform an Allen's test An Allen's test to asses circulation should be performed first. Next, hands should be washed, gloves applied, and a rolled towel should be placed under the client's wrist for support. The artery should be located and assessed for a strong pulse. The puncture site should be cleaned with an alcohol or povidine-iodine pad. The artery should be palpated with the index finger and middle fingers of one hand while holding the syringe over the puncture site with the other hand. Holding the needle bevel at a 30-45 degree angle, the skin and arterial wall should be punctured in one smooth motion. Blood should back flow into the syringe to the 5ml mark. After collecting the sample, press a gauze pad over the puncture sire for at least five minutes.
The nurse is evaluating an arterial blood gas result from a client with a closed head injury and notes the PaCO2 is 30mmHg. How should the nurse interpret this result? 1) Potentially appropriate, as modest lowering of carbon dioxide (CO2) may reduce intracranial pressure (ICP) 2) This client is poorly oxygenated and requires emergent and aggressive hyperventilation 3) This is a normal PaCO2 value 4) This client has alveolar hypoventilation
1) Potentially appropriate, as modest lowering of carbon dioxide (CO2) may reduce intracranial pressure (ICP) A normal PaCO2 value is 35-45 mmHg. CO2 has vasodilating properties. Lowering PaCO2 through hyperventilation may lower ICP. Hyperventilation should only be used for a short period of time, when immediate control of ICP is necessary. Oxygenation is evaluated through PaO2 and oxygen saturation. Alveolar hypoventilation would be reflected in an increased PaCO2.
A nurse is reviewing the assessment of a client with acute respiratory distress syndrome (ARDS). Which clinical data best indicates improvement in this client? 1) arterial blood gas (ABG) values 2) bronchoscopy results 3) increased blood pressure 4) sputum culture and sensitivity results
1) arterial blood gas (ABG) values Improved ABG results would indicate that this clients oxygenation status has improved. Hypoxia occurs with ARDS, so bronchoscopy and sputum culture results may have no bearing on the improvement of ARDS. Increased blood pressure isn't relative to the clients respiratory condition.
An 18 year old client, who was involved in a motor vehicle accident is admitted to the hospital with a diagnosis of pneumothorax. A chest tube is inserted and attached to a chest drainage system. The nurse notes almost constant bubbling in the water seal chamber. The nurse is aware that the bubbling is most likely the result of: 1) air leaks 2) adequate suction 3) inadequate suction 4) kinked chest tubes
1) air leaks Bubbling in the water seal chamber of a chest drainage system stems from an air leak. In pneumothorax, an air leak can occur as air is pulled from the pleural space. Bubbling doesn't normally occur with either adequate or inadequate suction. A kinked chest tube can stop the suction and any pre-existing bubbling in the water seal chamber.
The nurse is caring for a client in the immediate postoperative period. The nurse's priority would be to prevent: 1) atelectasis 2) bronchitis 3) pneumonia 4) pneumothorax
1) atelectasis atelectasis develops when there's interference with normal negative pressure that promotes lung expansion. Clients in the postoperative phase often splint their breathing because of pain and positioning, which causes hypoxia. It's uncommon for any of the other respiratory disorders to develop.
The nurse notes an order to change the client's chest drainage system from suction to gravity drainage. What is the most appropriate action by the nurse? 1) detach tubing from the suction port to provide a vent 2) clamp the client's drainage tube 3) question the health care provider's order 4) Turn off the suction source and leave the tubing connected.
1) detach tubing from the suction port to provide a vent When the suction source is turned off, the drainage system should be opened to the atmosphere so intrapleural air can escape from the system. Detaching the tuning from the suction port provides an exit vent for the air and reduces the risk of tension pneumothorax. Clamping the tube may cause air to accumulate in the pleural space, to leading to tension pneumothorax. There's no need to question the provider's order.
A nurse is making a home visit and finds an older client who requires immediate treatment for exposure to carbon monoxide. What priority action would the nurse take prior to the arrival of the paramedics? 1) loosen all tight fitting clothing 2) expose the client to fresh air 3) monitor for breathing difficulties 4) provide warm clothing or blanket
2) expose the client to fresh air the priority action is to expose the client to fresh air. The client should be moved away from carbon monoxide area. If the person is unconscious, check for injuries before moving. Call 911 and begin CPR if necessary.
A client who had a thoracotomy is using oxygen and having an arterial blood gas (ABG) analysis. What is the most appropriate information for the nurse to tell the client? 1) "I will shave the puncture site before the test" 2) "You need to keep the oxygen mask on for the entire test" 3) "You'll be suctioned immediately before the blood is drawn" 4) "You won't be allowed to drink anything for two hours before the blood is drawn"
2) "You need to keep the oxygen mask on for the entire test" To determine the effectiveness of oxygen therapy, ABGs should be drawn with the oxygen in use. No special preparations for the test, with regard to skin preparation or diet are needed. Suctioning decreases available oxygen.
The nurse suspects that a client is experiencing metabolic alkalosis based on laboratory and physical findings. Which findings best indicate this condition? 1) A pH of 7.30; HCO3 of 20 mEq/L; tachypnea and poor skin turgor 2) A pH of 7.51; HCO3 of 29 mEq/L; muscle cramps and confusion 3) A pH of 7.32; HCO3 of 48 mEq/L; shortness of breath and lethargy 4) A pH of 7.46; HCO3 of 28 mEq/L; dizziness and numbness of hands and feet
2) A pH of 7.51; HCO3 of 29 mEq/L; muscle cramps and confusion A pH greater than 7.45 and an HCO3 greater than 24 mEq/L indicate metabolic alkalosis. Physical findings for metabolic alkalosis include muscle spasms, twitching and notable confusion. A pH greater than 7.45 and PaCO2 less than 35 mmHg indicate respiratory alkalosis. Dizziness and numbness of hands and feet are symptoms of respiratory alkalosis. A pH less than 7.35 and HCO3 less than 22 mEq/L indicate metabolic acidosis. Rapid breathing and confusion/lethargy are symptoms of metabolic acidosis. A pH less than 7.35 and a PaCO2 greater than 45 mmHg indicate respiratory acidosis. Confusion, lethargy, and sob are symptoms of respiratory acidosis.
A client is involved in a motor vehicle accident. Upon admission to the emergency department, the clients heart rate was 130 bpm, with shallow respirations of 32 breaths/min and a blood pressure of 90/60 mmHg. The breath sounds were diminished on the right side and paradoxical chest wall movement appears on the right side. A chest X-ray reveals a right pneumothorax with multiple rib fractures. What diagnosis would the nurse anticipate for this client? 1) tension pneumothorax 2) flail chest 3) ruptured diaphragm 4) massive hemothorax
2) flail chest Multiple rib fractures and paradoxical chest wall movement would confirm a diagnosis of flail chest. Tension pneumothorax would cause severe respiratory distress, hypotension, diminished breath sounds over the affected area, hyper resonance, distended neck veins, eventual tracheal shift, and possibly paradoxical chest wall movement on the injured side. A ruptured diaphragm would lead to hyper resonance on percussion, hypotension, dyspnea, dysphagia, and shifting of heart and bowel sounds in the lower to middle chest. A massive hemothorax would produce signs of shock, dullness on percussion on the injured side, decreased breath sounds on the injured side, respiratory distress and possibly mediastinal shift.
A client is scheduled to have a chest tube removed. what is the priority nursing intervention prior to tube removal? 1) disconnect the drainage system from the tube 2) obtain a chest xray to document lung re-expansion 3) obtain arterial blood gases (ABG) to document oxygen status 4) sedate the client and have the health care provider remove the tube.
2) obtain a chest xray to document lung re-expansion A chest X-ray should be done to ensure the lung is re-expanded and has remained expanded since suction was discontinued. The drainage system shouldn't be disconnected from the tube until it has been removed because a pneumothorax could reoccur. A pulse oximetry measurement rather than ABG is sufficient to track oxygenation prior to tube removal. If the client can hold his breath while the chest tube is removed, there's less chance that air will be drawn back into the pleural space.
A client has developed a pleural effusion. What intervention would the nurse anticipate the health care provider to perform? 1) insert a chest tube 2) perform a thoracentesis 3) perform a paracentesis 4) allow the pleural effusion to drain by itself.
2) perform a thoracentesis Thoracentesis is used to remove excess pleural fluid and restore proper lung status. The fluid would be analyzed to determine if its transudative or exudative. A chest tube is rarely necessary because the amount go fluid typically isn't large enough to warrant such a measure. Paracentesis is the removal of fluid from the abdomen. Pleural effusions can't drain by themselves.
A nurse is preparing a client for chest tube insertion in the upper right chest. What is the priority role of the nurse? 1) a nurse isn't required 2) preparing the chest tube drainage system 3) bringing the chest X-ray to the clients room 4) inserting the chest tube
2) preparing the chest tube drainage system the nurse must anticipate that a drainage system will be required and the system readied prior to chest tube for immediate connection following insertion. The chest X-ray need not be brought into the clients room. A trained provider will insert the chest tube.
The nurse is assessing a client's chest tube and notes that it is not working properly. What is the nurse's priority action? 1) check for disconnection of the tubing from the drainage unit 2) clean the tips of the tubing and reconnect securely 3) Check the potency of the chest tube 4) submerge the end of the chest tube in one inch of sterile water.
3) Check the potency of the chest tube The most important action is to determine the potency of the chest tube. Checking for a disconnection would be the nurse's next action. Submerging the end of the chest tube in one inch of sterile water would only be necessary is the tube was disconnected and a chest drainage system was not available. Cleaning the tips of the tubing and reconnect securely would be necessary if the tube had become disconnected.
A client with pulmonary embolism has been placed on oxygen therapy. The nurse is reviewing lab work and determines that the therapy is effective when the lab work shows which value? 1) PaCO2 greater than 40 mmHg 2) PaCO2 less than 40 mmHg 3) PaO2 greater than 60 mmHg 4) PaO2 less than 60 mmHg
3) PaO2 greater than 60 mmHg The goal of oxygen therapy for a client with a pulmonary embolism is to have a PaO2 greater than 60 mmHg on FiO2 of 40% or less. The normal range of the PaCO2 is 35 to 45 mmHg. In the absence of other pathologic states, it should reach normal levels before the PaO2 does on room air because the carbon dioxide crosses the alveolar-capillary membrane with greater ease.
A client tell the nurse that his chest tube has been accidentally removed. What is the most appropriate action by the nurse? 1) Position the client on the left side 2) Position the client of the right side 3) apply an occlusive dressing over the site 4) reinsert the chest tube that fell out
3) apply an occlusive dressing over the site To prevent the client from sucking air into the pleural space and causing a pneumothorax, an occlusive dressing should be applied over the hole. The health care provider should be called, and the client checked for signs of respiratory distress. Positioning the client on either left of right side won't make a difference. The old tube should not be reinserted because it's no longer sterile.
A nurse is auscultating the lungs of a client following chest tube insertion. What assessment findings would indicate correct chest tube placement? 1) bronchial sounds heard at both bases 2) vesicular sounds heard over the upper lung fields 3) bronchovesicular sounds heard over both lung fields 4) crackles heard on the affected side
3) bronchovesicular sounds heard over both lung fields if the chest tube is inserted correctly normal brochovesicular breath sounds should be heard and the clients oxygenation status should improve. A chest X-ray should be done to ensure re-expansion. All other sounds noted are abnormal.
The nurse anticipates that the priority treatment for a client with spontaneous pneumothorax is: 1) antibiotics 2) bronchodilators 3) chest tube placement 4) hyperbaric chamber
3) chest tube placement The only way to re-expand a lung is place a chest tube so air in the pleural space can be removed and the lung re-expanded. Antibiotics and bronchodilators would have no effect on lung re-expansion, nor would placing the client in a hyperbaric chamber.
A client with cancer develops pleural effusion. What sound would the nurse expect to hear during chest auscultation? 1) Crackles 2) Rhonchi 3) diminished breath sounds 4) wheezes
3) diminished breath sounds In pleural effusion, fluid accumulates in the pleural space, impairing transmission of normal breath sounds. Breath sounds will be diminished. Crackles commonly accompany atelectasis, interstitial fibrosis, and left sided heart failure. Rhonchi suggest secretions in the large airways. Wheezes result from narrowed airways, as in asthma, chronic obstructive pulmonary disease or bronchitis.
The nurse reviews the arterial blood gas results of a client with asthma. The nurse is aware that the client's partial pressure of arterial oxygen (PaO2) result will provide information about: 1) respiratory status 2) the degree if dyspnea 3) efficiency of gas exchange 4) effectiveness of ventilation
3) efficiency of gas exchange The PaO2 reflects the gas exchange ventilation and perfusion. It doesn't measure the respiratory status, degree of dyspnea, or effectiveness of ventilation.
Which arterial blood gas results should a nurse expect to see in a client with emphysema? 1) pH 7.52; PaCO2 18 mmHg; HCO3 22 mEq/L 2) pH 7.50; PaCO2 38 mmHg; HCO3 38 mEq/L 3) pH 7.30; PaCO2 52 mmHg; HCO3 30 mEq/L 4) pH 7.30; PaCO2 40 mmHg; HCO3 18 mEq/L
3) pH 7.30; PaCO2 52 mmHg; HCO3 30 mEq/L Clients with emphysema retain carbon dioxide due to air trapping, causing an elevated PaCO2 and respiratory acidosis. Because emphysema is a chronic disease, the kidneys compensate over time for the increased PaCO2 by retaining HCO3 in an attempt to normalize the pH. The other ABG results aren't consistent with results found in a client with emphysema.
A 60 year old client involved in a motor vehicle accident was brought to the emergency department by paramedics. During the assessment, the client reports difficulty breathing and chest pain. Auscultation of the lung field reveals absent breath sounds in the left upper lobe. The nurse interprets this information as indicative of: 1) bronchitis 2) pneumonia 3) pneumothorax 4) tuberculosis (TB)
3) pneumothorax This client may have a left pneumothorax related to trauma. Auscultation would reveal rhonchi if this client had bronchitis, bronchial breath sounds if this client had pneumonia, and rhonchorous breath sounds with TB.
A clients arterial blood glass (ABG) results are: pH: 7.16 PaCO2: 80 mmHg HCO3: 24 mEq/L SaO2: 81% Based on these values, this client is showing signs of : 1) metabolic acidosis 2) metabolic alkalosis 3) respiratory acidosis 4) respiratory alkalosis
3) respiratory acidosis Because the clients PaCO2 is high and the HCO3 is normal, this client has respiratory acidosis. The clients pH is less than 7.35, which eliminates metabolic and respiratory alkalosis as possibilities. If the HCO3 was below 22 mEq/L, this client would have metabolic acidosis.
The arterial blood gas analysis of a child with asthma shows a pH of 7.30, PCO2 of 56 mmHg, and HCO3 of 25 mEq/L. Which condition does the child have? 1) metabolic acidosis 2) metabolic alkalosis 3) respiratory acidosis 4) respiratory alkalosis
3) respiratory acidosis Respiratory acidosis is an acid base disturbance characterized by excess CO2 in the blood, indicated by a PCO2 greater than 45mmHg. The pH level is usually below the normal range of 7.36-7.45. The HCO3 level is normal in the acute stage and elevated in the chronic stage.
A client with a history of myasthenia gravis is admitted to the emergency department with reports of respiratory distress. The client's condition worsens and arterial blood gases are drawn. For which condition is this client at risk? 1) metabolic acidosis 2) metabolic alkalosis 3) respiratory acidosis 4) respiratory alkalosis
3) respiratory acidosis The client has a restrictive lung problem because of myasthenia graves. This is aggravated by respiratory distress. Because of the restrictive problem, the client won't be able to exhale efficiently and carbon dioxide will build up causing respiratory acidosis. Metabolic acidosis is a condition that occurs with either accumulate of acids or excessive loss of bases in the body, such as in diarrhea or renal failure. Metabolic alkalosis occurs due to excessive acid loss or base retention from vomiting. Respiratory alkalosis results from a decreased carbon dioxide level, which could occur if the client were hyperventilating.
A nurse begins his shift by reading the following shift report. The nurse interprets these results as indicating which of the following? Miscellaneous reports: H.B. age 78; Hyperventilating, RR 36 bpm; C/o dizziness, sob, tingling in hands and feet, weakness; Anxious. ABG: pH 7.48; PaCO2: 33mmHg 1) metabolic acidosis 2) acute respiratory failure 3) respiratory alkalosis 4) anxiety reaction
3) respiratory alkalosis Respiratory alkalosis is defined by a pH of greater than 7.45 and PaCO2 less than 35mmHg and generally is associated with deep, rapid breathing, light headedness or dizziness; circumpolar and peripheral paresthesia; and carpopedal spasms, twitching, and muscle weakness as it progresses. Metabolic acidosis is defined as a pH less than 7.3 and PaCO2 less than or equal to 34mmHg depending on respiratory compensation and HCO3 less than 22mEq/L and is caused by an underlying non-respiratory disorder. Acute respiratory failure is characterized by a pH less than 3, PaCO2 greater than 50mmHg and markedly diminished oxygen saturation levels. Although the client may be anxious, the abnormal blood gas levels and corresponding symptoms indicate that treatment of respiratory alkalosis is the primary concern and may greatly reduce the client's anxiety level.
A client is suspected of having a pneumothorax. The nurse anticipates that this diagnosis will be confirmed by: 1) auscultating breath sounds 2) having the client use an incentive spirometer 3) reviewing the chest X-ray report 4) performing a thoracic puncture
3) reviewing the chest X-ray report A chest xray will reveal the area of collapsed lung, as well as the volume of air in the pleural space, if pneumothorax is present. Listening to breath sounds won't confirm a diagnosis. An incentive spirometer is used to encourage deep breathing. A needle thoracostomy is performed by trained personnel, and only in an emergency situation.
A client scheduled for a pneumonectomy asks the nurse how the thoracic cavity would be filled. What is the nurses best response? 1) The space remains filled with air only 2) The surgeon fills the space with a gel 3) serous fluid fills the space and consulates the region 4) the lung tissue from the remaining lung grows in the space.
3) serous fluid fills the space and consulates the region In the immediate post op period air and serous fluid fills the space. Eventually that area consolidates, preventing extensive mediastinal shift of the heart and remaining lung. Air can't be left in the space. Theres no gel that can be placed in the pleural space. The tissue from the other lung can't cross the mediastinum, although a temporary mediastinal shift exists until the space is filled.
A client with shortness of breath has decreased-to-absent breath sounds from the apex to the base of the lung on the right side. How would the nurse interpret this assessment finding? 1) acute asthma 2) chronic bronchitis 3) Pneumonia 4) spontaneous pneumothorax
4) spontaneous pneumothorax A spontaneous pneumothorax occurs when the client's lung collapses, causing an acute decrease in lung function. A sudden collapse with cause chest pain and shortness of breath. Wheezes would be heard if asthma were present, and the client with bronchitis would have rhonchi. Pneumonia would have bronchial breath sounds over the area on consolidation.
A nurse is assessing a client who has been given an opioid analgesic. Which arterial blood gas (ABG) value would indicate that this client is at risk for respiratory failure? 1) PaCO2 15mmHg 2) PaCO2 30 mmHg 3) PaCO2 40 mmHg 4) PaCO2 80 mmHg
4) PaCO2 80 mmHg A client with impending respiratory arrest will have insufficient ventilation, and will retain carbon dioxide. An ABG value of 80mmHg would indicate retained CO2. The other values are lower than expected.
A client's arterial blood gas (ABG) analysis reveals a pH of 7.18, PaCO2 of 73mmHg, PaO2 of 82mmHg, and HCO3 of 24 mEq/L. How would the nurse interpret these values? 1) Metabolic acidosis 2) Respiratory alkalosis 3) Metabolic alkalosis 4) Respiratory acidosis
4) Respiratory acidosis Normal ABG values include a pH of 7.35-7.45; PaCO2 of 35-45mmHg; PaO2 of 80-100mmHg; and HCO3 of 22-26 mEq/L. This clients pH level is acidic, the PaCO2 level is elevated, and the HCO3 is normal, indicating respiratory acidosis. With metabolic acidosis, pH and HCO3 are low and PaO2 is normal. In respiratory alkalosis, the pH is elevated and PaCO2 is low. In metabolic alkalosis, both pH and HCO3 are elevated.
The nurse is caring for a client with a pleural effusion. The client asks, "what's a pleural effusion?" what is the nurses most appropriate response? 1) collapse of the alveoli 2) collapse of bronchiole 3) fluid in the alveolar space 4) accumulation of fluid between the linings of the pleural space
4) accumulation of fluid between the linings of the pleural space Pleural fluid normally seeps continually into the pleural space from the capillaries lining the parietal pleura. This fluid is reabsorbed by the visceral pleural capillaries and lymphatics. Any condition that interferes with either the secretion or drainage of this fluid will lead to a pleural effusion. The collapse of alveoli or a bronchiole has no particular name. Fluid within the alveolar space can be caused by heart failure or adult respiratory distress syndrome.
A nurse is caring for a client who has just returned to the unit following a lobectomy. During assessment, the nurse is aware that the lobectomy site: 1) remains empty 2) is filled with a gel by the surgeon 3) is filled with serous fluid 4) is filled by overexpansion of the remaining lobes.
4) is filled by overexpansion of the remaining lobes. The remaining lobe or lobes over expand slightly to fill the space previously occupied by the tissue that has been removed. The diaphragm is carried higher on the operative side to further reduce empty space. The surgeon doesn't use gel to fill the space. Serous fluid overproduction would compress the remaining lobes, diminish their function, and possibly cause a mediastinal shift.
The nurse is caring for a client who has had a chest tube inserted for the treatment of a pneumothorax. Which assessment findings best indicates to the nurse that a chest tube is no longer needed? 1) there is minimal drainage from the chest tube. 2) arterial blood gas (ABG) results are within normal range. 3) the client states he is not experiencing dyspnea 4) no fluctuation in the water seal chamber occurs when no suction is applied.
4) no fluctuation in the water seal chamber occurs when no suction is applied. One indication of lung re-expansion is the cessation of fluctuation in the water seal chamber when suction isn't applied. Drainage should be minimal before the chest tube is removed. An ABG analysis may be done to ensure proper oxygenation but isn't necessary if other clinical assessment criteria are met. A chest tube isn't removed until the clients lung has adequately re-expanded and remains expanded.
A client with a massive pulmonary embolism us scheduled to have arterial blood gas analysis performed. The nurse expects the analysis will identify which condition? 1) metabolic acidosis 2) metabolic alkalosis 3) respiratory acidosis 4) respiratory alkalosis
4) respiratory alkalosis A client with massive pulmonary embolism will have a large region of lung tissue that is unavailable for perfusion. This will cause the client to hyperventilate and blow off large amounts of carbon dioxide which crosses the unaffected alveolar-capillary membrane more readily that does oxygen resulting in respiratory alkalosis.
Following a motor vehicle collision, a client has a chest tube inserted in the left upper chest. The tube begins to drain dark red fluid. What does the nurse determine? 1) the chest tube was inserted improperly 2) this is an expected result for this client 3) an artery was nicked when the chest tube was placed. 4) the client is experiencing a hemothorax.
4) the client is experiencing a hemothorax. this client has a hemothorax in which blood collection causes a lung to collapse. The placement of a chest tube will drain blood from the space and re-expand the lung. An intercostal artery can be nicked during the chest tube insertion, but the risk is minimal if the provider placing the tube is specifically trained. The initial chest X-ray would confirm the presence of blood or air in the pleural space.
