NSG 2400 Pneumothorax & Chest tubes

A nurse is caring for a client with a pneumothorax who has a chest tube in place. What should the nurse do when caring for this client? 1 Encourage range of motion to the client's arm on the affected side 2 Administer the prescribed cough suppressant at the prescribed times 3 Empty and measure the drainage in the collection chamber each shift 4 Apply clamps below the insertion site when getting the client out of bed

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A client is diagnosed with a spontaneous pneumothorax. Which physiologic effect of a spontaneous pneumothorax should the nurse include in a teaching plan for the client? 1 Air will move from the lung into the pleural space. 2 The heart and great vessels shift toward the affected side. 3 There is greater negative pressure within the chest cavity. 4 Collapse of the other lung will occur if not treated immediately.

1 As a person with a tear in the lung inhales, air moves through that opening into the intrapleural space; this creates a positive pressure and causes partial or complete collapse of the lung. Mediastinal shift occurs toward the unaffected side. Greater negative pressure within the chest cavity is normal; with a pneumothorax, there is a loss of intrathoracic negative pressure. Collapse of the other lung will occur if not treated immediately is not an impending problem.

What clinical indicators should the nurse expect to identify when assessing an individual with a spontaneous pneumothorax? Select all that apply. 1 Hematemesis 2 Shortness of breath 3 Unilateral chest pain 4 Increased thoracic motion 5 Mediastinal shift toward the involved side

2 3 With the reduction of surface area for gaseous exchange, the client experiences shortness of breath, tachycardia, and rapid, shallow respirations. Sudden chest pain occurs on the affected side; it may also involve the arm and shoulder. Bloody vomitus is unrelated to pneumothorax. Decreased chest motion occurs because of failure to inflate the involved lung. The shift toward the unaffected side results from pressure with the pneumothorax.

When a client suffers a complete pneumothorax, there is danger of a mediastinal shift. If such a shift occurs, what potential effect is a cause for concern? 1 Rupture of the pericardium 2 Infection of the subpleural lining 3 Decreased filling of the right side of the heart 4 Increased volume of the unaffected lung

3 Pressure within the pleural cavity causes a shift of the heart and great vessels to the unaffected side. This not only decreases the capacity of the unaffected lung but also impedes the filling of the right side of the heart and leads to a decreased cardiac output. Rupture of the pericardium might occur with severe chest trauma, not with a mediastinal shift. Infection is not caused by a mediastinal shift. The volume of the unaffected lung may decrease because of pressure from the shift.

A nurse is caring for a client with a pneumothorax who has a chest tube in place with a closed drainage system. Which of these actions by the nurse is correct? 1 Strip the chest tube periodically. 2 Administer the prescribed cough suppressant at the scheduled times. 3 Empty and measure the drainage in the collection chamber each shift. 4 Keep the drainage system lower than the level of the client's chest.

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A client comes to the emergency department reporting chest pain and difficulty breathing. A chest x-ray reveals a pneumothorax. Which finding should the nurse expect to identify when assessing the client? 1 Distended neck veins 2 Paradoxical respirations 3 Increasing amounts of purulent sputum 4 Absence of breath sounds over the affected area

4 When the lung is collapsed, air is not moving into and out of the area, and therefore breath sounds are absent. Distended neck veins are associated with failure of the right side of the heart and can occur with a mediastinal shift, but there is no evidence of either. Paradoxical respirations occur with flail chest, not pneumothorax. Purulent sputum is a sign of infection, not pneumothorax.

A client has a chest tube for a pneumothorax. The nurse finds the client in respiratory difficulty, with the chest tube separated from the drainage system. What should the nurse do? 1 Obtain a new sterile drainage system. 2 Use two clamps to close the drainage tube. 3 Place the client in the high-Fowler position. 4 Reconnect the client's tube to the drainage system.

4 To prevent further possibility of pneumothorax, the nurse should reconnect the tube immediately. Obtaining a new sterile drainage system is unnecessary. Clamping the tube is appropriate when changing a broken drainage system or when checking for an air leak. The high-Fowler position is appropriate for a client in respiratory distress, but it does not remedy the problem.

A client has a pneumothorax, and a closed-chest drainage system is inserted to allow the lung to reinflate. Identify the chamber in the figure below that provides the water seal.

C the chamber that goes to suction