NCLEX Questions- Care of a Client with a tube, Chest Tube

NCLEX Questions- Care of a Client with a tube, Chest Tube questions, CHEST TUBE questions Leave the first rating Students also studied Terms in this set (25) George Brown College Nursing Save Care of a Patient with a Chest Tube 26 terms lexi_adamsPreview

Chapter 22: Care of Patients with Ca...

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fran 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?

• Call the health care provider
• Place the tube in a bottle of sterile water
• Immediately replace the chest tube system
• Place a sterile dressing over the disconnection site
• 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 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.

• Excessive bubbling in the water seal chamber
• Vigorous bubbling in the suction control chamber
• Drainage system maintained below the client's chest
• 50 mL of drainage in the drainage collection chamber
• Occlusive dressing in place over the chest tube

insertion site

• 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.

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?

• Exhales slowly
• Stay very still
• Inhale and exhale quickly
• Perform the Valsalva maneuver
• 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?

• Call the health care provider to reinsert the tube.
• Grasp the retention sutures to spread the opening
• Call the respiratory therapy department to reinsert the

tracheotomy.

• Cover the tracheostomy site with a sterile dressing to

prevent infection.

• 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 caring for a client immediately after removal of the endotracheal tube. The nurse should report which sign immediately if experienced by the client?

• Stridor
• Occasional pink-tinged sputum
• Respiratory rate of 24 breaths/minute
• A few basilar lung crackles on the right
• 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 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?

• Do nothing, because this is an expected finding
• Check for an air leak because the bubbling should be

intermittent

• Increase the suction pressure so that the bubbling

becomes vigorous

• Immediately clamp the chest tube and notify the health

care provider

• 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 assessing a client with a chest tube. Upon examining the area around the chest tube she notes some swelling at the site and crepitus on palpation of the area. The nurse knows that this is subcutaneous emphysema. Her best course of action at this time is to

• Reassess the area in two hours
• Just monitor the area. The SC emphysema will resolve

on its own.

• Notify the physician.
• Apply nonocclusive dressing to the site.
• Notify the physician

You are the RN taking care of a client with a chest tube.During your assessment you note that the tube has become disconnected from CDU unit. Your priority action is to

• Notify the physician
• Cover the end of the chest tube with an occlusive

dressing.

• Submerge the tube 1 to 2 inches below the surface of a

bottle of sterile water.

• Immediately reconnect the tubing to the CDU unit to

prevent a pneumothorax.

• Submerge the tube 1 to 2 inches below the surface of a bottle of sterile water.

The nurse is taking care of a client with a chest tube. On entering the clients room she notes the client is experiencing extreme dyspnea and is cyanotic. On further assessment he appears to have tracheal deviation to the left. The nurse suspects a tension pneumothorax.The nurse knows the immediate treatment for a pneumothorax is to

• apply supplemental oxygen per nonrebreather mask
• Insert a needle into the left 2nd intercostal space in the

mid-clavicular line to decompress the pneumothorax

• Sit the client in the semi-fowlers position and apply O2

to maintain SaO2 > 95%

• Insert a needle into the right and intercostal space in

the mid-clavicular line to decompress the pneumothroax

• Insert a needle into the left 2nd intercostal space in the mid-clavicular line to

decompress the pneumothorax The nurse is caring for a client who will be undergoing a chest tube insertion. The nurse knows she needs to have the following supplies at the bedside. Select all that apply.

• CDU unit
• Supplemental O2
• Standby emergency airway equipment
• Suction
• Thoracotomy tray

A, B, C, E

The nurse is assessing the CDU unit of a client with a chest tube. She notes continuous bubbling in the water- seal chamber. She suspects a leak in the system. The most appropriate action for the nurse is to

• Milk or strip the tubing to identify where the leak it
• Do nothing, the leak is outside the lung so will not have

any effect on the chest tube

• Immediately change CDU unit
• Momentarily clamp the tubing at various points to

locate the air leak

• Momentarily clamp the tubing at various points to locate the air leak

The nurse is caring for a client who will be undergoing chest tube insertion. She will be assisting with the procedure. The nurse knows the most common location for chest tube insertion is

• Second intercostal space, mid axillary line
• Third intercostal space mid axillary line, lateral to the

nipple

• Mid axillary line between the 4th and 5th ribs on a line

lateral to the nipple

• At the base of the ribs to allow for better fluid

drainage

• Mid axillary line between the 4th and 5th ribs on a line lateral to the nipple

The nurse is caring for a client who has returned from surgery where they underwent a thoracotomy. A chest tube is in place. The nurse knows that the purpose of this chest tube is to

• Remove air or fluid thus restoring negative pressure

within the pleural space to re expand the lung.

• To collect blood for autotransfusion
• To instill fluids into the pleural space
• Equalize pressure inside and outside the pleural space
• Remove air or fluid thus restoring negative pressure within the pleural space to

re expand the lung The nurse is taking care of a client with a chest tube. On her initial assessment for the day she notes the chest tube has come out and is lying in the bed beside the client.Her immediate reaction is to

• Cover the hole with an occlusive dressing and notify

the physician

• Apply supplemental O2 and notify the physician
• Cover the hole with a sterile dressing and notify the

physician

• Call respiratory therapy to reinsert the chest tube
• Cover the hole with an occlusive dressing and notify the physician

You are an RN taking care of a client with a chest tube.On your assessment you note the client has improved respiratory status, symmetrical rise & fall of the chest, and normal bilateral breath sounds. There is minimal chest tube drainage and absence of bubbling in the water-seal chamber during expiration. The most likely explanation for these findings is

• These are expected findings in a client with a chest

tube and you will continue to monitor

• The absence of bubbling indicates an air leak in the

system

• The lung has re expanded and these are indications for

chest tube removal.

• There is fluid in the tubing occluding the chest tube
• The lung has re expanded and these are indications for chest tube removal