eaq chest trauma
Which statement made by the patient indicates effective learning about the interventions to be followed to reduce the risk of atelectasis while undergoing chest tube drainage? Select all that apply.
"I should cough at regular intervals." "I should perform incentive spirometer." "I should perform range-of-motion exercises.
What instructions would the nurse give to the patient with a cervical spine injury who, during follow-up visits, shows improvement? Select all that apply.
"You may sleep on the injured side if your breathing is comfortable." "You may sleep in a semi-Fowler's position."
A patient sustained injuries to the chest and extremities during a street fight. The patient reports shortness of breath. The patient's breath sounds are decreased on the right side, the right lung is dull on percussion, and the blood pressure is 80/50 mm Hg. The primary health care provider is preparing to insert a chest tube for drainage. The nurse is aware that what size chest tube will be used?
38F
Which statement is true regarding a flutter valve?
A flutter valve allows patient mobility.
The nurse is caring for a patient who had a recent lung transplant. The nurse knows which statements are correct? Select all that apply.
Accurate diagnosis of rejection is by transtracheal biopsy. Cytomegalovirus (CMV) pneumonia is the most common opportunistic infection. Lung transplant recipients usually receive higher levels of immunosuppressive therapy than other organ recipients.
Which complication does the nurse expect when a patient with fractured ribs is wearing a binder on the chest?
Atelectasis
One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing interventions?
Chest tube with a loose-fitting dressing
The senior nurse is evaluating the actions of the student nurse, who is maintaining the drainage system in a patient with chest trauma. Which intervention made by the student nurse indicates the need for further teaching? Select all that apply.
Coiling the tubing above the chest level Connecting the chest tube to wall suction to check tidaling
A patient with a spontaneous pneumothorax has a chest tube that is attached to a closed drainage system. The drainage unit is not attached to suction. The water level in the water-seal chamber is fluctuating. What action should the nurse take?
Continuing to monitor and document the respiratory status
The nurse, while examining a patient with chylothorax, finds that the patient has lymphatic flow of 3000 mL/day. The primary health care provider prescribes pleurodesis for the patient. Which other medication does the nurse expect in the patient's prescription?
Doxycycline
Which type of chest surgery is indicated for a patient with chest trauma?
Exploratory thoracotomy
Which type of pneumothorax does the nurse anticipate from a post-surgical patient with a sucking chest wound after a thoracotomy?
Iatrogenic pneumothorax
The nurse is assessing a patient who has a closed chest tube drainage system attached to a water-seal chamber. The nurse notes that the tidaling has stopped. What is the priority intervention by the nurse?
Investigate the chest tube for a possible occlusion.
Which statement is true regarding a water-seal chamber?
It contains 2 cm of water.
How will splinting the incision with a pillow benefit a patient who underwent surgery to repair chest trauma?
It will facilitate deep breathing.
The nurse is caring for a patient who is at risk for a flail chest. The nurse knows which statements are true? Select all that apply.
Palpation must be performed to check for crepitus. Most patients with a flail chest require mechanical ventilation.
The nurse finds that a patient with chest trauma exhibits cyanosis, air hunger, distension of the neck vein, profuse diaphoresis, and an increase of intrathoracic pressure. What is the priority procedure in this situation?
Performing needle decompression
The diagnostic reports of a patient indicate that the patient has chylothorax. The primary health care provider has prescribed octreotide. What outcome does the nurse expect after treatment?
Reduced flow of lymphatic fluid
The nurse is assessing a patient with chest trauma who is on chest-tube gravity drainage. While assessing, the nurse finds that the fluid level in the chamber is very high. What is the best nursing intervention in this situation?
Releasing the high negativity valve
A patient is diagnosed with a pneumothorax, and the health care provider has inserted a chest tube with chest drainage system. The nurse who is monitoring the system finds that there is no bubbling. The nurse checked all the connections and found no problems. What are the most probable reasons for the absence of bubbling? Select all that apply.
Suction pressure is very low. Pleural air leak is too large to be drained. Suctioning is not present.
The nurse is caring for a patient who is on a chest drainage tube with wet suction system. The nurse finds that the suction control chamber has no bubbles. What does the nurse expect from this finding?
The patient has a high pleural air leak.
What does the nurse interpret from finding excessive bubbling in the water-seal chamber while monitoring a patient who is on chest tube drainage?
The patient may have a bronchopleural leak.
Which outcome does the nurse expect from administering patient-controlled analgesia (PCA) to the patient who has undergone thoracotomy? Select all that apply.
The patient will have effective cough. The patient will be able to take deep breaths. The patient will be able to move the arm on the operative side.
What does the nurse infer from finding that a patient with a pneumothorax has limited fluid accumulated in the intrapleural space, with no other body parts affected?
The patient will have spontaneous resolution.
Which type of surgery allows the surgeon to manipulate instruments passed into the pleural space?
Video-assisted thoracoscopic surgery
A patient has a chest tube inserted to treat a spontaneous pneumothorax. Which observation causes the nurse to conclude that the water-seal chamber of the closed chest drainage system is functioning properly?
Water-seal chamber level fluctuating with respirations
Which condition in a patient with chest trauma requires treatment of positive pressure ventilation?
flail chest
The nurse is assessing different patients who are undergoing the process of chest drainage using a chest drainage system. Which patient will require -10 cm H 2O?
pt A
The nurse is caring for a patient who has had a left pneumonectomy. What is an appropriate nursing intervention for a patient postpneumonectomy?
range of motion
What is the most evident symptom of flail chest in an unconscious patient?
shallow respiration
Which condition does the nurse expect is present in a patient with chronic obstructive pulmonary disorder (COPD) who has a rupture of small blebs on the apex of the lung?
spontaneous
What does the nurse interpret from findings of swelling in the head and neck and compromised airways in a patient who has an iatrogenic pneumothorax and is going through the process of chest tube drainage?
subcut emphysema
