NCLEX Questions- Care of a Client with a tube

The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial nursing action should the nurse take? 1. Call the health care provider 2. Place the tube in a bottle of sterile water 3. Immediately replace the chest tube system 4. Place a sterile dressing over the disconnection site

2. Rationale-If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The HCP may need to be notified, but this is not the initial action. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection.

The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is most appropriate? 1. Do nothing, because this is an expected finding 2. Check for an air leak because the bubbling should be intermittent 3. Increase the suction pressure so that the bubbling becomes vigorous 4. Immediately clamp the chest tube and notify the health care provider

1. Rationale-Continuous gentle bubbling should be noted in the suction control chamber. Bubbling should be continuous in the suction control chamber and not intermittent. Increasing the suction pressure only increased the rate of evaporation of water in the drainage system; in addition, increasing the suction can be harmful and is not done without a specific prescription to do so. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy).

The nurse is caring for a client immediately after removal of the endotracheal tube. The nurse should report which sign immediately if experienced by the client? 1. Stridor 2. Occasional pink-tinged sputum 3. Respiratory rate of 24 breaths/minute 4. A few basilar lung crackles on the right

1. Rationale-Following removal of the endotracheal tube the nurse monitors the client for respiratory distress. The nurse reports stridor to the health care provider (HCP) immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction. Although the findings identified in the remaining options require monitoring, they do not require immediate notification of the health care provider.

The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action? 1. Exhales slowly 2. Stay very still 3. Inhale and exhale quickly 4. Perform the Valsalva maneuver

4. Rationale-When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an air-tight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed.

While changing the tapes on a tracheotomy tube, the client coughs and the tube is dislodged. Which is the initial nursing action? 1. Call the health care provider to reinsert the tube. 2. Grasp the retention sutures to spread the opening 3. Call the respiratory therapy department to reinsert the tracheotomy. 4. Cover the tracheostomy site with a sterile dressing to prevent infection.

2. Rationale-If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures and spread the opening. If agency policy permits, the nurse then attempts immediately to replace the tube. Calling ancillary services or the HCP will delay treatment in this emergency situation. Covering the tracheostomy sire will block the airway.

The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. 1. Excessive bubbling in the water seal chamber 2. Vigorous bubbling in the suction control chamber 3. Drainage system maintained below the client's chest 4. 50 mL of drainage in the drainage collection chamber 5. Occlusive dressing in place over the chest tube insertion site 6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhlation

3,4,5, and 6. Rationale-The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure, and may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has reexpanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more than 70 to 100mL/hour is considered excessive and requires health care provider notification. The chest tube insertion site is covered with an occlusive (air-tight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.