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concept of nursing 2
closed chest drainage system- lesson 2
| Question | Answer |
|---|---|
| A patient has returned from the operating room with a chest tube in his sixth intercostal space with orders to connect the patient to wall suction. The patient has a three-chamber water-seal system. | -- |
| Eight hours later the nurse finds the patient complaining of increased chest pain, a respiratory rate of 40, and a pulse of 110. The water-seal chamber is dry. The patient is in obvious distress. | -- |
| What should the nurse suspect as the primary cause for the respiratory distress? | There is no water in the water-seal chamber. |
| What effect will increasing the suction source, creating more negative pressure, have on a three-chamber water-seal chest tube drainage system connected to suction? | It will create more vigorous bubbling and faster evaporation of water. |
| The nurse is monitoring the functioning of a three-chamber water-seal drainage system. Which of the following would negatively affect the functioning of this type of chest tube drainage system? | -Evaporation of water in the water-seal chamber. -Evaporation of water in the suction control chamber. -If the chest tube drainage system is tipped over. |
| The nurse is assessing a waterless chest drainage system. Which of the following would be cause for concern? | Continuous bubbling is present in the diagnostic air-leak indicator. |
| What is the importance of keeping water at the prescribed centimeter level in the suction control chamber? | As the fluid level decreases with evaporation, the amount of suction declines. |
| Which of the following tasks associated with a chest tube is the responsibility of the nurse? | Setting up equipment, positioning the patient, and monitoring patient status. |
| During assessment of a patient's record, what items are areas of concern that should be brought to the attention of the health care provider before chest tube insertion? | -The patient has had a stroke and is receiving anticoagulants. -The patient has arthritis, which is being treated with aspirin. -The patient regularly uses an antiplatelet agent. |
| -- | -The patient has a hemoglobin value of 9 g per dL. -A consent form lacks a signature. |
| What clinical signs and symptoms should a nurse expect in a patient who requires chest tube insertion for a pneumothorax? | -Shallow respirations at a rate greater than 20 breaths per minute. -Anxious and restless. -Diaphoretic. -Cyanotic. -Chest pain. |
| A patient with a hemothorax has a posterior chest tube located laterally in the fifth intercostal space connected to a water-seal drainage system. Preprocedure vital signs were: | -- |
| Temperature 98.6° F, pulse 110, respiration 26 and shallow, blood pressure 94/52, and oxygen saturation 87%. The nurse is evaluating the patient's outcome. The health care provider should be notified of which of the following findings? | -Temperature 98.0° F, pulse 124, respiration 28, blood pressure 80/50, pulse oximetry 85%. -Bright red drainage 8 hours after insertion in the collection chamber. -Asymmetrical chest movement. |
| A nursing student is helping care for a patient with a chest tube. The nursing student asks the staff nurse what determines the level of suction in the chest tube. What is the correct response? | -"The depth of fluid in the suction control chamber of a water-seal system determines the highest amount of negative pressure that can be present within the system." |
| -- | -"The suction float ball indicates the amount of suction the patient's intrapleural space is receiving in a waterless system." |
| Which postprocedure chest tube insertion vital sign schedule meets the minimum needs of a postoperative patient? | Every 15 minutes for the first 2 hours. |
| What is a normal expected outcome after insertion of a chest tube? | Normal rate and depth of breathing. |
| An RN and an NAP are caring for a group of patients. Which of the following would be an appropriate action for the nurse? | -Delegate to the NAP informing the nurse if there is disconnection of the chest tube system or sudden bleeding. |
| The nurse is assisting the health care provider with the insertion of a chest tube. Before the procedure, the nurse prepares the drainage system to ensure that it will operate correctly. The nurse opens the drainage system and | -- |
| adds sterile water to the suction control chamber according to the manufacturer’s directions. The nurse then connects the tubing to the suction control chamber and to the suction source. The nurse clamps the tube that will go to the patient and turns | -- |
| the suction on to check the system for any air leaks. Because no air leaks are found, the nurse unclamps the tube and leaves the suction on so that it is ready to be connected to the patient. Which step made by the nurse requires correction? | The nurse should turn the suction off before it is connected to the patient. |
| The nurse is assisting the health care provider with the insertion of a chest tube. Which of the following activities, if performed by the nurse, requires correction? | The nurse tapes the connection between the chest tube and the drainage tube with a figure-eight pattern and makes sure the tubing is coiled on the floor. |
| Which of the following findings in a patient with a chest tube would require follow-up by the nurse? | -Sudden increase of 300 mL drainage in 1 hour. -Constant right-to-left bubbling in the diagnostic air-leak indicator. -Constant bubbling in the water seal. |
Created by:
Lightnning54
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