The nurse is presenting a class on chest tubes. which statement describes a tension pneumothorax?

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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?

1. Bronchovesicular lung sounds and bradypnea.
2. Unequal lung expansion and dyspnea.
3. Frothy bloody sputum and consolidation.
4. Barrel chest and polycythemia.

1. The client with pneumothorax would have absent breath sounds and tachypnea.
***2. Unequal lung expansion and dyspnea would indicate a pneumothorax.
3. Consolidation occurs when there is no air moving through the alveoli as in pneumonia; frothy sputum occurs with congestive heart failure.
4. Barrel chest and polycythemia are signs of chronic obstructive pulmonary disease.

TEST-TAKING HINT: The test taker can use "chest trauma" or "pneumothorax" to help select the correct answer. Both of these words should cause the test taker to select "2" because unequal chest expansion would result from trauma.

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?

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

1. A STAT chest x-ray would not be needed to determine why there is no fluctuation in the water-seal compartment.
2. Increasing the amount of wall suction does not address why there is no fluctuation in the water-seal compartment.
***3. The key to the answer is "2 hours." The air from the pleural space is not able to get to the water-seal compartment, and the nurse should try to determine why. Usually the client is lying on the tube, it is kinked, or there is a dependent loop.
4. The stem does not state that the client is in respiratory distress, and a pulse oximeter read- ing detects hypoxemia but does not address any fluctuation in the water-seal compartment.

TEST-TAKING HINT: The test taker should apply the nursing process to answer the question correctly. The first step in the nursing process is assessment and "check" (option "3") is a word that can be used synonymously for assess. Monitoring (option "4") is also assess- ing, but the test taker should not check a diagnostic test result before caring for the client.

Which intervention should the nurse implement for a male client who has had a left- sided chest tube for six (6) hours and refuses to take deep breaths because it hurts too much?

1. Medicate the client and have the client take deep breaths.
2. Encourage the client to take shallow breaths to help with the pain.
3. Explain that deep breaths do not have to be taken at this time.
4. Tell the client that if he doesn't take deep breaths, he could die.

***1. The client must take deep breaths to help push the air out of the pleural space into the water-seal drainage, and deep breaths will help prevent the client from develop- ing pneumonia or atelectasis.
2. The client must take deep breaths; shallow breaths could lead to complications.
3. Deep breaths must be taken to prevent complications.
4. This is a cruel intervention; the nurse can medicate the client and then encourage deep breathing.

TEST-TAKING HINT: If the test taker reads options "2" and "3" and notices that both reflect the same idea namely, that deep breaths are not necessary then both can either be eliminated as incorrect answers or kept as possible correct answers. Option "4" should be eliminated based on being a very rude and threatening comment.

The unlicensed nursing assistant is assisting the client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention from the nurse?

1. The client's chest tube is below the level of the chest.
2. The nursing assistant has the chest tube attached to suction.
3. The nursing assistant allowed the client out of the bed.
4. The nursing assistant uses a bedside commode for the client.

1. Keeping the drainage system lower than the chest promotes drainage and prevents reflux.
***2. The chest tube system can function as a result of gravity and does not have to be attached to suction. Keeping it attached to suction could cause the client to trip and fall. Therefore, this is a safety issue and the nurse should intervene and explain this to the nursing assistant.
3. Ambulation facilitates lung ventilation and expansion; drainage systems are portable to allow ambulation while chest tubes are in place.
4. The client should ambulate, but getting up and using the bedside commode is better than stay- ing in the bed, so no action would be needed.

TEST-TAKING HINT: "Warrants immediate intervention" means the test taker must identify the situation in which the nurse should intervene and correct the action, demonstrate a skill, or somehow intervene with the unlicensed assistant's behavior.

The client has a right-sided chest tube. As the client is getting out of the bed it is acci- dentally pulled out of the pleural space. Which action should the nurse implement first?

1. Notify the health-care provider to have chest tubes reinserted STAT.
2. Instruct the client to take slow shallow breaths until the tube is reinserted.
3. Take no action and assess the client's respiratory status every 15 minutes.
4. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site.

1. The health-care provider will have to be noti- fied, but this is not the first intervention. Air must be prevented from entering the pleural space from the outside atmosphere.
2. The client should breathe regularly or take deep breaths until the tubes are reinserted.
3. The nurse must take action and prevent air from entering the pleural space.
***4. Taping on three sides prevents the development of a tension pneumothorax by inhibiting air from entering the wound during inhalation but allowing it to escape during exhalation.

TEST-TAKING HINT: The word "first interven- tion" in the stem of the question indicates to the test taker that possibly more than one (1) intervention could be indicated in the situa- tion but only one (1) is implemented first. Remember, do not select assessment first without reading the question. If the client is in any type of crisis, then the nurse should first do something to help the client's situation.

The nurse is presenting a class on chest tubes. Which statement describes a tension pneumothorax?

1. A tension pneumothorax develops when an air-filled bleb on the surface of the lung ruptures.
2. When a tension pneumothorax occurs, the air moves freely between the pleural space and the atmosphere.
3. The injury allows air into the pleural space but prevents it from escaping from the pleural space.
4. A tension pneumothorax results from a puncture of the pleura during a central line placement.

1. This is incorrect information. It is the description of a spontaneous pneumothorax.
2. This is the description of an open pneumothorax.
***3. This describes a tension pneumothorax. It is a medical emergency requiring immediate intervention to preserve life.
4. This is called an iatrogenic pneumothorax, which also may be caused by thoracentesis or lung biopsy. A tension pneumothorax could occur from this procedure, but it does not describe a tension pneumothorax.

TEST-TAKING HINT: The test taker must always be clear about what the question is asking before answering the question. If the test taker can eliminate options "1" and "2" and can't decide between "3" and "4," the test taker must go back to the stem and clarify what the question is asking.

Which action should the nurse implement for the client with a hemothorax who has a right-sided chest tube and there is excessive bubbling in the water-seal compartment?

1. Check the amount of wall suction being applied.
2. Assess the tubing for any blood clots.
3. Milk the tubing proximal to distal.
4. Encourage the client to cough forcefully.

***1. Checking to see if someone has increased the suction rate is the simplest action for the nurse to implement; if it is not on high, then the nurse must check to see if the problem is with the client or the system.
2. No fluctuation (tidaling) would cause the nurse to assess the tubing for a blood clot.
3. The tube is milked to help dislodge a blood clot that may be blocking the chest tube causing no fluctuation (tidaling) in the water- seal compartment. The chest tube is never stripped, which creates a negative air pressure and would suck lung tissue into the chest tube.
4. Encouraging the client to cough force fully will help dislodge a blood clot that may be blocking the chest tube, causing no fluctuation (tidaling) in the water-seal compartment.

TEST-TAKING HINT: The test taker should always think about assessing the client if there is a problem and the client is not in immediate danger. This would cause the test taker to eliminate options "3" and "4." If the test taker thinks about bubbling, he or she should know it has to do with suctioning.

Which assessment data indicate that the chest tubes have been effective in treating the client with a hemothorax who has a right-sided chest tube?

1. There is gentle bubbling in the suction compartment.
2. There is no fluctuation (tidaling) in the water-seal compartment.
3. There is 250 mL of blood in the drainage compartment
4. The client is able to deep breathe without any pain.

1. This is an expected finding in the suction compartment of the drainage system that indicates adequate suctioning is being applied.
***2. At three (3) days post-insertion, no fluctuation (tidaling) indicates the lung has reexpanded, which indicates the treatment has been effective.
3. Blood in the drainage bottle is expected for a hemothorax but does not indicate the chest tubes have reexpanded the lung
4. Taking a deep breath without pain is good, but it does not mean the lungs have reexpanded.

TEST-TAKING HINT: The test taker must be knowledgeable about chest tubes to be able to answer this question. The test taker must know the normal time frame and what is expected for each compartment of the chest tube drainage system.

The nurse is caring for a client with a right-sided chest tube secondary to a pneu- mothorax. Which interventions should the nurse implement when caring for this client? Select all that apply.

1. Place the client in a low-Fowler's position.
2. Assess chest tube drainage system frequently.
3. Maintain strict bed rest for the client.
4. Secure a loop of drainage tubing to the sheet.
5. Observe the site for subcutaneous emphysema.

1. The client should be in a high-Fowler's posi- tion to facilitate lung expansion.
***2. The system must be patent and intact to function properly.
3. The client can have bathroom privileges, and ambulation facilitates lung ventilation and expansion.
***4. Looping the tubing prevents direct pres- sure on the chest tube itself and keeps tubing off the floor, addressing both a safety and an infection control issue.
***5. Subcutaneous emphysema is air under the skin, which is a common occurrence at the chest tube insertion site.

TEST-TAKING HINT: The test taker should be careful with adjectives. In option "1" the word "low" makes it incorrect; in option "3," the word "strict" makes this option incorrect.

The charge nurse is making client assignments on a medical floor. Which client should the charge nurse assign to the LPN?

1. The client with pneumonia who has a pulse oximeter reading of 91%.
2. The client with a hemothorax who has Hgb of 9 mg/dL and Hct of 20%.
3. The client with chest tubes who has jugular vein distention and BP of 96/60.
4. The client who is two (2) hours post-bronchoscopy procedure.

1. This pulse oximeter reading indicates the client is hypoxic and therefore is not stable and should be assigned to an RN.
2. This H&H are very low; therefore the client is not stable and should be assigned to an RN.
3. Jugular vein distention and hypotension are signs of a tension pneumothorax, which is a medical emergency, and the client should be assigned to an RN.
***4. A client that is two (2) hours post- bronchoscopy procedure could safely be assigned to an LPN.

TEST-TAKING HINT: The test taker must under- stand that the LPN should be assigned the least critical client or the client that is stable and not exhibiting any complications second- ary to the admitting disease or condition.

The alert and oriented client is diagnosed with a spontaneous pneumothorax, and the physician is preparing to insert a left-sided chest tube. Which intervention should the nurse implement first?

1. Gather the needed supplies for the procedure.
2. Obtain a signed informed consent form.
3. Assist the client into a side-lying position.
4. Discuss the procedure with the client.

1. The nurse should gather a thoracotomy tray and the chest tube drainage system and take it to the client's bedside, but it is not the first intervention.
***2. The insertion of a chest tube is an invasive procedure and so requires informed con- sent. Without a consent form, this procedure cannot be done on an alert and oriented client.
3. This is a correct position to place the client for a chest tube insertion, but it is not the first intervention.
4. The physician will discuss the procedure with
the client, then informed consent must be obtained, and then the nurse can do further teaching.

TEST-TAKING HINT: The test taker must know that invasive procedures require informed consent and legally it must be obtained first before anyone can touch the client.

Which intervention should the nurse implement first for the client diagnosed with a hemothorax who has had a right-sided chest tube for three (3) days and has no fluctu- ation (tidaling) in the water compartment?

1. Assess the client's bilateral lung sounds.
2. Obtain an order for a STAT chest x-ray.
3. Notify the health-care provider as soon as possible. 4. Document the findings in the client's chart.

***1. Assessment of the lung sounds could indi- cate that the client's lung has reexpanded because it has been three (3) days since the chest tube has been inserted.
2. This should be done to ensure that the lung has reexpanded, but it is not the first intervention.
3. The HCP will need to be notified so that the chest tube can be removed, but it is not the first intervention.
4. This situation needs to be documented, but it is not the first intervention.

TEST-TAKING HINT: When the stem asks the test taker to identify the first intervention, all four (4) answer options could be interventions that are appropriate for the situation, but only one (1) is the first intervention. Remember to apply the nursing process: the first step is assessment.

Which of the following statements is true about intrapleural (the space between the parietal and visceral or pulmonary pleurae) pressure under normal conditions?
A. It is always positive
B. It is negative during inhalation; positive during exhalation
C. It is positive during inhalation; negative during exhalation
D. It is always negative

D.

A patient with an opening in the chest wall, such as from a gunshot, stab wound or impalement, resulting in "sucking chest wound" can be said to have:
A. An open pneumothorax
B. A closed pneumothorax
C. A hemothorax
D. A pleural effusion

A.

In self-contained, disposable chest drains, the manual high negative pressure relief valve
A. Allows water to be added to the system without disconnecting the patient tubing
B. Alerts the nurse to a situation of high pressure within the system and automatically vents
C. Allows filtered atmospheric air into the system to offset a rise in negative pressure
D. Alerts the nurse to high suction levels accumulating in the system

C.

In a self-contained, disposable chest drain, the amount of negative pressure transmitted to the patient by suction is determined by:
A. The amount of suction set on the wall vacuum regulator
B. The sensitivity of the high negative pressure relief valve
C. The dial setting on the suction control chamber
D. The level of water in the water seal chamber

C.

A physician has just performed a thoracostomy for a pleural effusion. The nurse handed the patient tubing from the drain to the physician, who attached it to the chest tube. The drain is properly filled with water and placed in an upright position below the patient's chest. The physician orders suction to the chest drain system. With a dry suction control chamber (as is present in the Atrium Oasis), how should the nurse adjust the vacuum source?
A. Adjust the vacuum source until the dial on the vacuum regulator reads -20mmHg
B. Adjust the vacuum source until constant, gentle bubbling just begins in the suction control chamber
C. Adjust the vacuum source until the bellows indicator is all the way to the right of the indicator window
D. Adjust the vacuum source until the bellows indicator reaches the arrow mark in the indicator window

D.

Which of the following statements is true regarding patient movement while requiring chest drainage? (assume a physician order or protocol exists)
A. Patients may go only from bed to a chair while the chest tube is connected to a chest drain
B. If patient must leave nursing unit, suction tubing should be clamped shut while chest drain is disconnected from suction
C. If a patient is ambulatory, the chest tube should be clamped shut while the chest drain is disconnected from suction
D. Patients may walk around once the nurse disconnects the drain from suction as long as the drain remains below the chest

D.

If the chest tube is pulled out of the patient's chest, and the patient had an air leak from the lung, after asking a colleague to call a physician STAT, emergency nursing management is to:
A. Cover the opening with a sterile dressing, taped on three sides
B. Cover the opening with a sterile Vaseline gauze, taped securely on all sides
C. Leave the opening alone and monitor the patient until a physician can assess the situation
D. Try to put the tube back in place as quickly as possible

A.

If there is an air leak from the lung into the pleural space, the dressing applied to the patient's chest should mimic the function of the chest drainage system - allow air to escape from the pleural space while minimizing air re-entering the pleura from the atmosphere. If an occlussive dressing was applied, no air could escape the pleural space and the pneumothorax could develop into a tension pneumothorax.

Which of the following situations is likely to result in an absence of fluctuations in the chest drainage tubing?
A. The tubing is coiled on the bed with a straight path to the chest drain
B. The tubing is blocked in some way
C. The patient is receiving positive pressure ventilation
D. The patient is ambulatory

B.

New bubbling is observed in the water seal chamber after a patient with a pleural chest tube returns from a test. The nurse clamps the chest tube momentarily with a tubing clamp at the dressing site. When this is done, bubbling in the water seal stops. The next appropriate nursing action is to:
A. Continue to monitor the water seal chamber for bubbling every hour for the next four hours
B. Do nothing. This bubbling is normal in patients with pleural chest tubes
C. Call the physician immediately and do not leave the patient's bedside because of the risk of respiratory failure
D. Remove the chest tube dressing to see if one or more eyelets of the chest tube have been pulled out of the chest

D.

When is it beneficial to clamp a patient's chest tube?
A. When ordered by a physician to simulate tube removal and assess the patient's response
B. Whenever a patient leaves the nursing unit and cannot be monitored
C. When ambulating a postoperative patient with a chest tube
D. It is never beneficial to clamp a patient's chest tube

A.

Which of the following signs indicates a chest tube may be removed?
A. Drainage is approximately 100mL/hr in a patient with pleural chest tube following spinal surgery
B. The chest radiograph shows only a small residual pneumothorax in a patient requiring mechanical ventilation
C. Bubbling in the water seal has been absent for 24 hours following iatrogenic pneumothorax from CVP placement
D. Fluctuations in the water seal are approximately 2 to 4cmH2O with each breathing cycle

C.

The water seal is the most important element of the drainage system because:
A. It indicates patency of the tubing by tidaling with inspiration and expiration
B. It allows air to enter the pleural space but prevent air from exiting the pleural space through the chest tube
C. It allows air to exit the pleural space but prevent air from entering the pleural space through the chest tube
D. It allows air to move freely in and out of the pleural space through the chest tube.

C.

The following would result in a loss of the water seal:
A. Momentary tipping-over of the Atrium drainage system.
B. Evaporation of the water in the water seal chamber below the 2 cm mark.
C. Suction removed or turned off.
D. The drainage chambers are full.

B.

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How would you describe tension pneumothorax?

Which signs and symptoms would the nurse expect to observe with a tension pneumothorax?

Which of the following is a physical finding of tension pneumothorax?

How does chest tube cause tension pneumothorax?