Chapter 19_ Care of the Eye and Ear _ Nursing School Test Banks

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Chapter 26: Closed Chest Drainage Systems MULTIPLE CHOICE 1. The nurse is caring for a patient who is comatose and on a ventilator. When she enters the room, she notices that the patient’s trache... a has shifted toward the left side of the patient’s neck, and he has become tachycardic. She assesses the patient’s blood pressure and notes that it is 84/38. The nurse calls for help, having recognized that the patient has developed which of the following conditions? a. Hemothorax b. Pneumothorax on the left side c. Pneumothorax on the right side d. Myocardial infarction ANS: C A tension pneumothorax occurs from rupture in the pleura when air accumulates in the pleural space more rapidly than it is removed. If left untreated, the lung on the affected side collapses, and the mediastinum and the trachea shift to the opposite (unaffected) side. The patient has sudden chest pain, a fall in blood pressure, and tachycardia, and cardiopulmonary arrest can occur. Patients with chest trauma, fractured ribs, and invasive thoracic bedside procedures (such as insertion of central lines) and those on high­pressure mechanical ventilation are at risk for tension pneumothorax. A hemothorax is a collapse of the lung caused by an accumulation of blood and fluid in the pleural cavity between the chest wall and the lung, usually as a result of trauma. Nothing in this scenario would suggest myocardial infarction. Students Chat Room 15 2/20/2017 Chapter 26: Closed Chest Drainage Systems | Nursing School Test Banks https://nursingtestbank.info/chapter­26­closed­chest­drainage­systems/ 2/24 DIF: Cognitive Level: Synthesis REF: Text reference: p. 656 OBJ: List three conditions requiring chest tube insertion. TOP: Pneumothorax KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. For a patient with a pneumothorax, where does the nurse anticipate that the chest tube will be located? a. Second to third intercostal space (apical), anterior b. Fifth to sixth intercostal space, posterior c. Fifth to sixth intercostal space, lateral d. Mediastinal area ANS: A Apical (second or third intercostal space) and anterior chest tube placement promotes removal of air, which is necessary in the case of a pneumothorax. Chest tubes are placed low (usually in the fifth or sixth intercostal space) and posterior or lateral to drain fluid. A mediastinal chest tube is placed in the mediastinum, just below the sternum. This tube drains blood or fluid, preventing its accumulation around the heart. A mediastinal tube commonly is used after open heart surgery. DIF: Cognitive Level: Analysis REF: Text reference: p. 656 OBJ: List three common sites for chest tube placement. TOP: Chest Tube Position KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. The patient’s chest tube is attached to a one­way flutter valve that allows air to escape the chest cavity and prevents air from reentering. How does the nurse document this finding? a. Heimlich chest drain valve Students Chat Room 15 2/20/2017 Chapter 26: Closed Chest Drainage Systems | Nursing School Test Banks https://nursingtestbank.info/chapter­26­closed­chest­drainage­systems/ 3/24 b. Pneumovax c. Water seal d. Pleurovac ANS: A The device described is a Heimlich chest drain valve. Pneumovax is a pneumococcal vaccine that is effective against 23 common strains of Pneumococcus. A Pleurovac is the brand name of a water­seal set. DIF: Cognitive Level: Knowledge REF: Text reference: p. 657 OBJ: Define the key terms used in the care of patients with chest tubes. TOP: Type of Chest Tube KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The nurse is caring for a patient who has a chest tube connected to a water seal. The patient is not on a ventilator. Which of the following would the nurse consider normal? a. The fluid level in the water seal rises with inspiration. b. The fluid level in the water seal falls with inspiration. c. Constant bubbling occurs in the water seal. d. The fluid level in the water seal falls with expiration 3 days after insertion. ANS: A Students Chat Room 15 2/20/2017 Chapter 26: Closed Chest Drainage Systems | Nursing School Test Banks https://nursingtestbank.info/chapter­26­closed­chest­drainage­systems/ 4/24 Observe the water seal for intermittent bubbling from its U tube or for a rise and fall of fluid that is synchronous with respirations. (For example, in a nonmechanically ventilated patient, the fluid rises during inspiration, and the fluid level falls during expiration. When a patient is on a mechanical ventilator, the opposite occurs.) In a nonmechanically ventilated patient, the fluid rises during inspiration, and the fluid level falls during expiration. Constant bubbling in the water seal or a sudden, unexpected stoppage of water­seal activity is considered abnormal and requires immediate attention. After 2 to 3 days, tidaling or bubbling on expiration is expected to stop, indicating that the lung has reexpanded. DIF: Cognitive Level: Analysis REF: Text reference: p. 658 OBJ: Discuss the nursing principles involved in caring for patients with chest tubes. TOP: Water­Seal Tidaling KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 5. The nurse is caring for a patient with a chest tube that was inserted 4 days earlier. She notices that the drainage contains a large amount of pus. What does the presence of the pus indicate? a. Malignancy b. Pulmonary infarction c. Empyema d. Hemothorax ANS: C Pus indicates an empyema, which is a collection of pus in the pleural cavity, and the drainage is pus colored. Blood­tinged fluid usually indicates malignancy, pulmonary infarction, or severe inflammation. Frank blood indicates a hemothorax. DIF: Cognitive Level: Knowledge REF: Text reference: p. 658 Students Chat Room 15 2/20/2017 Chapter 26: Closed Chest Drainage Systems | Nursing School Test Banks https://nursingtestbank.info/chapter­26­closed­chest­drainage­systems/ 5/24 OBJ: Discuss the nursing principles involved in caring for patients with chest tubes. TOP: Pleural Drainage KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. What is indicated by continuous bubbling in the water­seal chamber with no bubbles noted in the suction control chamber of the drainage system? a. A leak in the system b. Normal functioning c. A drainage obstruction d. Insufficient suction pressure ANS: A Continuous bubbling in the water­seal chamber with an absence of bubbles in the suction control chamber indicates that there is a leak in the system. Normal functioning is indicated by gentle, continuous bubbling in the suction chamber and occasional bubbling in the water seal, with fluctuations on inspiration and expiration. Constant bubbling in the water seal or a sudden, unexpected stoppage of water­seal activity is considered abnormal and requires immediate attention. Insufficient suction pressure has little to no bubbling in the suction chamber. DIF: Cognitive Level: Analysis REF: Text reference: p. 659 OBJ: Describe methods of troubleshooting chest tube systems. TOP: Bubbling in Suction Control Chamber KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. What condition is indicated when a patient with a chest tube experiences sharp, stabbing chest pain without a change in pulse or blood pressure? Students Chat Room 15 2/20/2017 Chapter 26: Closed Chest Drainage Systems | Nursing School Test Banks https://nursingtestbank.info/chapter­26­closed­chest­drainage­systems/ 6/24 a. Pneumonitis b. Tube displacement c. A myocardial infarction d. A tension pneumothorax ANS: D Sharp, stabbing chest pain with or without decreased blood pressure and increased heart rate may indicate a tension pneumothorax. A chest tube is not an expected treatment for pneumonitis. Tube displacement is an unexpected outcome and can lead to increased pneumothorax. Immediately apply pressure over the chest tube insertion site. Myocardial infarction pain is expressed as “crushing” or “pressure” over the sternal area. DIF: Cognitive Level: Analysis REF: Text reference: p. 662 OBJ: Describe methods of troubleshooting chest tube systems. TOP: Tension Pneumothorax KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 8. Which of the following is an expected outcome of chest tube insertion? a. Mild chest pain is maintained. b. Breath sounds are auscultated in all lobes. c. Drainage from the pleural cavity increases over time. d. Lung expansion is increased beyond the unaffected side. Students Chat Room 15 2/20/2017 Chapter 26: Closed Chest Drainage Systems | Nursing School Test Banks https://nursingtestbank.info/chapter­26­closed­chest­drainage­systems/ 7/24 ANS: B When breath sounds are auscultated in all lobes, lung expansion is symmetrical, oxygen saturation (SaO ) is stable or improved, and respirations are nonlabored. Chest pain is not an expected outcome. Treatment is effective when the patient reports no chest pain. Drainage from the pleural cavity decreases over time with reexpansion of the lung. Lung expansion would be equal to preinjury status. DIF: Cognitive Level: Knowledge REF: Text reference: p. 663 OBJ: Describe methods of troubleshooting chest tube systems. TOP: Expected Outcomes of Chest Tube Insertion KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. What should the nurse do to establish a two­chamber waterless chest tube system? a. Add sterile water to the suction chamber b. Add sterile solution to the water seal c. Set the float ball to the correct drainage pressure d. Connect directly to the chest tube and add nothing [Show More]

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