Chest Trauma NCLEX

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francis_j_crupi Preview NCLEX 25 terms klh2 A patient has a chest tube inserted for a pneumothorax.What should the nurse expect when assessing the drainage system?

• periodic bubbling in the water seal chamber

immediately after insertion

• no evidence of tidaling
• vigorous bubbling in the suction control chamber
• large amount of bloody drainage in the drainage

collection chamber 1.

Global Rationale: When a chest tube is inserted in the pleural space for a

pneumothorax, the trapped air is allowed to escape and periodic bubbling is observed in the water seal as the lung reexpands. The water column in the water seal should rise with inspiration and fall with expiration (tidaling). There should be gentle bubbling in the suction control chamber to avoid rapid evaporation of the fluid in the chamber. Large amounts of bloody drainage would be anticipated after chest tube insertion for hemothorax.The nurse is caring for a patient on mechanical ventilation with positive end expiratory pressure (PEEP). When assessing the patient, which finding would indicate the possibility of tension pneumothorax?

• new onset of absent breath sounds over the right lung
• blood pressure of 170/80
• pulse oximetry readings ranging from 94% to 96%
• crackles and wheezing heard in both lungs

1.

Global Rationale: In a tension pneumothorax, air enters the pleural space with

each breath but does not exit. Progressive accumulation of air in the pleural space leads to collapse of the lung on the affected side and hypoxia. As a result, the patient would have absent breath sounds on the affected side rather than adventitious sounds (crackles and wheezes). As the pressure in the thorax increases, cardiac output declines and the patient becomes hypotensive. A pulse oximetry reading of 94?monstrates adequate oxygenation.The nurse is assessing a patient recovering from a motor vehicle crash. Which assessment finding indicates that the patient is experiencing a pneumothorax?

• hyperresonance to percussion at the apex of the left

lung

• dullness to percussion at the base of the left lung
• crackles throughout the left lung
• shallow breathing

1.

Global Rationale: In pneumothorax, the percussion tone is hyperresonant due to

the trapped air in the pleural space. Dullness to percussion is suggestive of fluid accumulation, such as in hemothorax. Crackles in the left lung suggest fluid accumulation in the alveoli. Shallow breathing can occur but is not specific to pneumothorax. It would also be seen in rib fractures and flail chest.

A 20-year-old patient who is asking questions about smoking cessation tells the nurse about an upcoming class on scuba diving. The nurse recognizes that this patient might be at risk for developing what health problem?

• pleural effusion
• pleurisy
• pneumothorax
• hemothorax

3.

Global Rationale: Primary pneumothorax affects previously healthy people,

usually tall, slender men between ages 16 and 24. The cause of primary pneumothorax is unknown. Risk factors include smoking. Certain activities also increase the risk of spontaneous pneumothorax, such as high-altitude flying and rapid decompression during scuba diving. The patient's age, smoking status, and scuba diving interest do not increase the risk for developing a pleural effusion, pleurisy, or a hemothorax.The nurse observes air bubbles in a patient's chest tube water seal chamber. How should the nurse interpret this finding?

• normal
• an emergency
• an indication that the pneumothorax is worsening
• an indication to remove the chest tube

1.

Global Rationale: Periodic air bubbles in the water-seal chamber are normal and

indicate that trapped air is being removed from the chest. This is not an emergency situation, or one that indicates a worsening condition. The nurse would need a physician's order to remove a chest tube. The patient still needs the chest tube in place.During the assessment of a patient's respiratory status, the nurse notes paradoxical lung movements. This finding is consistent with what health problem?

• flail chest
• pleurisy
• pneumothorax
• pneumonia

1.Global Rationale: Physiologic function of the chest wall is impaired as the flail segment is sucked inward during inhalation and moves outward with exhalation.This is known as paradoxic movement. This movement is not associated with pleurisy, pneumothorax, or pneumonia.A patient is diagnosed with a tension pneumothorax.What should the nurse expect to assess in this patient?

Standard Text: Select all that apply.

• hypertension
• distended neck veins
• bradycardia
• absent breath sounds on the affected side
• tracheal deviation toward unaffected side

2, 4, 5

Global Rationale: Manifestations of a tension pneumothorax include hypotension,

shock, distended neck veins, severe dyspnea, tachypnea, tachycardia, decreased respiratory excursion, absent breath sounds on affected side, and tracheal deviation toward unaffected side.

The student nurse is learning how to care for patients who had thoracic surgery following a diagnosis of lung cancer. The intensive care unit nurse is assessing the student's understanding. Which statements by the student indicate the need for further education?

Standard Text: Select all that apply.

• "I should assess the patient's respiratory system at least

every four hours."

• "I really shouldn't even offer narcotic pain medications

to this patient because it will result in severe respiratory depression."

• "If there are items that the patient needs frequently, I

should keep them across the hospital room. This will ensure that the patient will get better faster."

• "The patient's head of bed should be maintained

between 15 and 30 degrees."

• "The area between the visceral and parietal pleura

must be filled with positive pressure to work appropriately, and this can be accomplished with a functioning chest tube."

2, 3, 4, 5

Global Rationale: Narcotic pain medications should be offered after thoracic

surgery to ensure that the patient can perform pulmonary rehabilitation exercises such as coughing, deep breathing, and incentive spirometry. The patient who is using narcotic pain medications to achieve pain control must be monitored for respiratory depression so that it can be treated. This patient should be encouraged to conserve energy. Items that are used frequently should be kept within the patient's reach. The nurse should elevate the head of the bed to 60 degrees, because elevating the head of the bed reduces pressure on the diaphragm and permits optimal lung expansion. The area between the visceral and parietal pleura must be filled with negative pressure to work appropriately.The chest tube is used to achieve negative pressure within this space. The nurse should perform a respiratory assessment at least every four hours.The healthcare provider is caring for a patient who has a pneumothorax. When assessing the patient and the chest tube drainage system, a large fibrin clot is noted in the tubing. Which additional assessment finding requires immediate action by the healthcare provider?A downward trend in blood pressure Clots in the system can cause occlusion and lead to a tension pneumothorax, which may be evidenced by a downward trend in blood pressure as increased pressure on the heart and great vessels impair cardiac output.The healthcare provider is assisting during the insertion of a pulmonary artery catheter. Which of these, if assessed in the patient, would indicate the patient is experiencing a complication from the catheter insertion?Tracheal deviation from midline A patient who is attached to a chest tube drainage unit is being transported from the emergency department to the respiratory care unit. Which of these actions should be performed by the healthcare provider in preparation for the transport?Secure the chest tube unit on the gurney.The chest tube drainage unit must always be kept below the patient's chest level to facilitate drainage and avoid backward flow of pleural drainage.When caring for a patient who has a pneumothorax, which of these actions should the healthcare provider include in the patient's plan of care?Encourage the patient to breathe deeply and cough regularly.Regular deep breathing and coughing will help re-expand the collapsed lung.A patient has undergone open heart surgery for a congenital heart defect and has a chest tube drainage system in place. If there is damage to the thoracic duct during the procedure, what type of fluid will the healthcare provider observe in the collection chamber?milky white The thoracic duct is a major lymphatic vessel.Which of these individuals is at risk for a primary spontaneous pneumothorax?

• ft. 138 lb pt. who smokes

A primary spontaneous pneumothorax occurs most commonly in young males who are tall and thin.

A patient who has a diagnosis of pneumonia reports a sudden onset of sharp pain on one side of the chest. The patient is dyspneic and oxygen saturation falls to 89%, percent. After administering oxygen to the patient, which of these actions should the healthcare provider perform next?Auscultate the lungs bilaterally If breath sounds are distant or absent on one side, the healthcare provider will suspect a pneumothorax.The healthcare provider enters the room of a patient with a diagnosis of tuberculosis and finds the patient dyspneic.The neck veins are also visibly distended. Which of these additional assessments should the healthcare provider perform immediately?Palpate for tracheal deviation Pressure will eventually build up causing a shift of the mediastinal structures from midline.When receiving report during the transfer of a patient who has a pneumothorax, the healthcare provider is told that the patient has subcutaneous emphysema. Which assessment finding will validate this statement?A crackling sensation when the chest is palpated If air leaks into the subcutaneous tissue, a crackling or popping sensation can be felt on palpation.The healthcare provider is caring for four patients. Which patient should be assessed first?RR 28 asymmetrical chest movement Tachypnea and asymmetric chest wall movement are signs of a pneumothorax, so this patient needs prompt assessment and intervention.The client is admitted to the emergency department with chest trauma. When assess- ing the client, which signs/symptoms would the nurse expect to find that support the diagnosis of pneumothorax?

• Bronchovesicular lung sounds and bradypnea.
• Unequal lung expansion and dyspnea.
• Frothy bloody sputum and consolidation.
• Barrel chest and polycythemia.

2.The client had a right-sided chest tube inserted two (2) hours ago for a pneumothorax. Which action should the nurse take if there is no fluctuation (tidaling) in the water- seal compartment?

• Obtain an order for a stat chest x-ray.
• Increase the amount of wall suction.
• Check the tubing for kinks or clots.
• Monitor the client's pulse oximeter reading.

3.