Chest Tubes & EKG

Which action would the nurse take to determine patency of the chest tube and closed chest drainage system in a client after left lower lobectomy?

Observe for fluctuations of the fluid in the water-seal chamber.

When a client's cardiac monitor shows ventricular tachycardia, which action would the nurse take first?

Check for a pulse.

When caring for a client after a thoracotomy, which action would the nurse take to keep the chest tube and closed chest drainage system patent?

Position the drainage system below the level of the client's heart.

Which finding in a client who has had a chest tube removed would be of most concern to the nurse?

Crepitus at the chest tube site

A client who had thoracic surgery is admitted to the postanesthesia care unit. The nurse notes that a chest tube is in place and is attached to a disposable plastic, water-seal drainage system. To provide appropriate care of the chest tube and drainage unit, which step would the nurse take next?

Ensure the security of the connections from the client to the drainage unit.

Which action would the nurse take to prevent complications when caring for a client with a chest tube to water seal drainage system for a pneumothorax? Select all that apply. One, some, or all responses may be correct.

Marking the time on the drainage unit every shift

The nurse is assessing an electrocardiogram (ECG) rhythm strip. Which component of the tracing will the nurse observe to determine ventricular depolarization?

QRS Complex

Which actions will the nurse include in the plan of care for a client with a left pneumothorax who has a chest tube in place? Select all that apply. One, some, or all responses may be correct.

Check the water-seal chamber for air bubbling. Assist the client to cough and deep breathe every hour while awake.

Which finding best indicates that the chest tube for a client with a pneumothorax may be discontinued?

Full re-expansion of the lungs seen on chest x-ray

Which actions will the nurse take when caring for a client with a chest tube in place after thoracotomy? Select all that apply. One, some, or all responses may be correct.

Administer prescribed analgesic medications. Check around chest tube insertion site for crepitus. Add fluid to the suction control chamber as needed. Check for air bubbling in the water-seal chamber.

When a client who has a chest tube after thoracotomy reports sharp chest pain at the chest tube and refuses to take deep breaths, which action by the nurse is best?

Administer prescribed pain medications.

When a client has sinus tachycardia, which potential causes of the dysrhythmia would the nurse consider when assessing the client? Select all that apply. One, some, or all responses may be correct.

Anxiety Caffeine Exercise Anemia

When the nurse in the coronary care unit (CCU) identifies ventricular fibrillation on a client's cardiac monitor, which intervention is the priority?

Defibrillate the client.

When caring for a client with symptomatic bradycardia caused by heart block, the nurse will anticipate the need to teach the client about which treatment option?

Demand pacemakers

A nurse is caring for a client with a pneumothorax who has a chest tube attached to a closed chest drainage system. If the chest tube and closed chest drainage system are effective, which type of pressure will be reestablished?

Negative pressure in the pleural space

Which information would be used to determine the cause of premature atrial contractions (PACs) observed on a client's EKG? Select all that apply. One, some, or all responses may be correct.

Stress level Tobacco use Caffeine intake Electrolyte levels Home medications

Which action is essential for the nurse to include in the plan of care for a client with atrial fibrillation?

Take pulse apically for a full minute.

Which action would the nurse include in the plan of care for a client who had an ischemic stroke caused by atrial fibrillation and has been placed on anticoagulation therapy to prevent further strokes from occurring? Select all that apply. One, some, or all responses may be correct.

Wearing a medical alert bracelet Initiating bleeding precautions Refraining from estrogen therapy Obtaining routine prothrombin times Notifying providers of anticoagulation

Which action would the nurse perform when a client is in ventricular fibrillation? Select all that apply. One, some, or all responses may be correct.

Initiating CPR Assessing the EKG Using a defibrillator Obtaining electrolytes Administering epinephrine