Chapter 28: Supporting Ventilation

Question 1

The nurse is reviewing the function of chest tubes with a group of students. Which statement indicates a correct understanding of their purpose?

A. “Chest tubes are inserted to create positive pressure in the pleural space.”

B. “Chest tubes are used to re-establish negative pressure in the pleural space.”

C. “The goal of chest tubes is to increase the amount of air in the pleural space.”

D. “Chest tubes prevent fluid accumulation in the alveoli.”

Answer 1

B. “Chest tubes are used to re-establish negative pressure in the pleural space.”

Rationale: The pleural space normally has a negative pressure that allows the lungs to stay inflated. A chest tube re-establishes this negative pressure by draining air or fluid, promoting lung expansion.

Question 2

Which clinical scenario requires the insertion of a large (36F to 40F) chest tube?

A. Spontaneous pneumothorax
B. Hemothorax
C. Pleural effusion
D. Tension pneumothorax

Answer 2

B. Hemothorax

Rationale: Large chest tubes (36F to 40F) are used to drain blood from the pleural space, as seen in a hemothorax. Smaller tubes (12F to 24F) are sufficient for air drainage, and medium tubes (24F to 36F) are often used for fluid drainage in conditions like pleural effusion.

Question 3

A nurse notices continuous bubbling in the water-seal chamber of a patient’s chest tube drainage system. What is the most appropriate initial action by the nurse?

A. Check for air leaks in the system.
B. Increase the suction pressure.
C. Clamp the chest tube.
D. Notify the provider immediately.

Answer 3

A. Check for air leaks in the system.

Rationale: Continuous bubbling in the water-seal chamber may indicate an air leak. The nurse should first check the system for leaks. Clamping the tube or increasing suction pressure is not appropriate as initial actions. The provider should be notified only if the issue cannot be resolved.

Question 4

A patient undergoing chest tube insertion is given a local anesthetic. Which area is most likely to be anesthetized for the procedure?

A. The lower abdomen
B. The diaphragm
C. The intercostal muscles at the insertion site
D. The chest wall at the insertion site

Answer 4

D. The chest wall at the insertion site

Rationale: The local anesthetic is injected into the chest wall at the insertion site to numb the area where the incision is made, ensuring the patient remains comfortable during the procedure.

Question 5

The nurse is preparing a patient for chest tube insertion. What is the primary purpose of elevating the patient’s head to 45 degrees during the procedure?

A. To reduce the risk of aspiration
B. To improve lung expansion
C. To lower the diaphragm and reduce the risk of injury
D. To increase the patient’s comfort during the procedure

Answer 5

C. To lower the diaphragm and reduce the risk of injury

Rationale: Elevating the head of the bed up to 45 degrees lowers the diaphragm, which reduces the risk of injury to the diaphragm during chest tube insertion.

Question 6

What is the most appropriate action if a chest tube is inserted at the bedside, but the healthcare provider is unable to confirm tube placement immediately?

A. Continue with the procedure and wait for the patient to stabilize
B. Perform a chest x-ray to confirm the chest tube placement
C. Reassure the patient and monitor vital signs
D. Withdraw the chest tube and insert a new one immediately

Answer 6

B. Perform a chest x-ray to confirm the chest tube placement

Rationale: Tube placement is confirmed by a chest x-ray after insertion to ensure it is in the correct location and functioning properly.

Question 7

After a chest tube is inserted, the healthcare provider sutures the tube in place and covers the wound with an occlusive dressing. What is the rationale for using petroleum gauze around the chest tube insertion site?

A. To create an airtight seal
B. To prevent infection
C. To minimize pain during the procedure
D. To allow drainage of any residual air or fluid

Answer 7

A. To create an airtight seal

Rationale: Petroleum gauze is used to seal the wound around the chest tube to create an airtight seal, preventing air from entering the pleural space and ensuring proper chest tube function.

Question 8

During chest tube insertion, why does the healthcare provider insert the tube up and over the top of the rib rather than below the rib?

A. To avoid damaging the intercostal nerves and blood vessels
B. To ensure easier drainage of blood from the pleural space
C. To reduce the risk of puncturing the lung
D. To prevent damage to the diaphragm

Answer 8

A. To avoid damaging the intercostal nerves and blood vessels

Rationale: The chest tube is advanced up and over the top of the rib to avoid the intercostal nerves and blood vessels that lie behind the rib inferiorly.

Question 9

A nurse is assisting with the insertion of a chest tube for a patient with a pneumothorax. Which position should the nurse place the patient in for the procedure?

A. Supine with the affected arm at the side
B. Prone with the head elevated
C. Sitting upright with the head tilted forward
D. Lying on the unaffected side with the arm raised above the head

Answer 9

D. Lying on the unaffected side with the arm raised above the head

Rationale: The patient is positioned with the arm raised above the head on the affected side to expose the midaxillary area, which is the standard site for chest tube insertion.

Question 10

A nurse is caring for a patient with a chest tube after surgery. The patient has 250 mL of drainage in the first hour. What should the nurse do?

A. Continue to monitor the drainage as normal.

B. Notify the healthcare provider (HCP) immediately.

C. Increase the suction pressure on the drainage system.

D. Administer a diuretic to reduce the drainage amount.

Answer 10

B. Notify the healthcare provider (HCP) immediately.

Rationale: Rationale: The nurse should notify the HCP if drainage exceeds 200 mL in the first hour, as this may indicate excessive fluid or blood removal that can lead to complications, including re-expansion pulmonary edema or severe hypotension.

Question 11

What is the priority nursing action if a chest tube becomes disconnected from the drainage system?

A. Immerse the exposed end of the chest tube in sterile water.

B. Clamp the chest tube immediately to prevent air from entering.

C. Replace the chest drainage system right away.

D. Apply a sterile dressing to the chest tube insertion site.

Answer 11

A. Immerse the exposed end of the chest tube in sterile water.

Rationale: If the chest tube becomes disconnected, the immediate priority is to re-establish the water-seal system. The exposed end of the tube should be immersed in sterile water until a new drainage system is set up to prevent a tension pneumothorax.

Question 12

A nurse palpates a “crackling” sensation around the chest tube insertion site. What does this indicate?

A. Subcutaneous emphysema.
B. Infection at the insertion site.
C. Air leak in the drainage system.
D. Accumulation of blood in the pleural space.

Answer 12

A. Subcutaneous emphysema.

Rationale: The “crackling” sensation is indicative of subcutaneous emphysema, which occurs when air leaks into the tissue around the chest tube insertion site. A small amount of subcutaneous air is typically harmless, but significant emphysema around the neck or face can cause airway compromise.

Question 13

What is the most appropriate nursing intervention to reduce the risk of atelectasis and shoulder stiffness in a patient with a chest tube?

A. Encourage the patient to lie flat and rest.

B. Encourage coughing, deep breathing, and range-of-motion exercises.

C. Restrict the patient from moving their affected arm.

D. Use a heating pad over the shoulder area.

Answer 13

B. Encourage coughing, deep breathing, and range-of-motion exercises.

Rationale: To prevent atelectasis and shoulder stiffness, the nurse should encourage the patient to engage in coughing, deep breathing, and use an incentive spirometer. Range-of-motion exercises also help to reduce shoulder stiffness.

Question 14

A nurse is assessing a patient with a chest tube and notices new intermittent bubbling in the water-seal chamber. What is the nurse’s priority action?

A. Increase the suction pressure to −40 cm H2O.
B. Clamp the chest tube immediately to stop the bubbling.
C. Assess the drainage system for an air leak.
D. Notify the healthcare provider about the bubbling.

Answer 14

C. Assess the drainage system for an air leak.

Rationale: New intermittent bubbling in the water-seal chamber can indicate an air leak. The nurse should assess the drainage system to determine whether the leak is coming from the patient or the system itself.

Question 15

What is the primary concern if a large amount of fluid (1 to 1.5 L) is removed rapidly from the pleural space after chest tube insertion?

A. Hypovolemic shock due to rapid blood loss.
B. Severe pain and discomfort in the chest.
C. Air embolism causing respiratory arrest.
D. Re-expansion pulmonary edema or severe hypotension.

Answer 15

D. Re-expansion pulmonary edema or severe hypotension.

Rationale: Rapid removal of large amounts of fluid can lead to re-expansion pulmonary edema or severe symptomatic hypotension. This can occur due to the rapid re-expansion of the lung and changes in intrathoracic pressure.

Question 16

A nurse is caring for a patient with a chest tube. When is it appropriate to clamp the chest tube momentarily?

A. To assess for subcutaneous emphysema.
B. When disconnecting the drainage system for transport.
C. To check for air leaks or change the drainage apparatus.
D. To prevent an air leak during coughing.

Answer 16

C. To check for air leaks or change the drainage apparatus.

Rationale: The chest tube can be momentarily clamped to assess for air leaks or to change the drainage apparatus. However, clamping should be done according to agency policy, and the tube should never be clamped for extended periods due to the risk of tension pneumothorax.

Question 17

A nurse is caring for a patient with a chest tube attached to a drainage system. The nurse observes intermittent bubbling in the water-seal chamber. What is the most likely explanation for this finding?

A. The chest tube is obstructed.
B. The air leak in the pleural space is resolving.
C. The patient is developing a tension pneumothorax.
D. The suction control chamber is malfunctioning.

Answer 17

B. The air leak in the pleural space is resolving.

Rationale: Intermittent bubbling in the water-seal chamber can occur during exhalation, coughing, or sneezing as intrathoracic pressure changes. This is common as the air leak in the pleural space resolves, and the lung becomes more fully expanded.

Question 18

What does the term “tidaling” in the water-seal chamber of a chest drainage system indicate?

A. A blockage in the chest tube
B. Increased air leak from the pleural space
C. Malfunctioning of the suction control chamber
D. Normal movement of water with the patient’s breathing

Answer 18

D. Normal movement of water with the patient’s breathing

Rationale: Tidaling refers to the normal up and down movement of water in the water-seal chamber that reflects changes in intrapleural pressure during inspiration and expiration.

Question 19

A nurse notices that tidaling has stopped suddenly in the water-seal chamber of a patient’s chest drainage system. What is the most appropriate action for the nurse to take?

A. Increase the suction pressure.
B. Continue to monitor the patient’s condition.
C. Assess the chest tube for occlusion.
D. Notify the provider immediately.

Answer 19

C. Assess the chest tube for occlusion.

Rationale: A sudden stop in tidaling may indicate that the chest tube is occluded. The nurse should assess the tube to determine if there is a blockage or issue with the drainage.

Question 20

In a water suction chest drainage system, how is the amount of suction applied to the pleural space determined?

A. By the dial on the chest drainage unit
B. By the height of the water-seal chamber
C. By the size of the chest tube used
D. By the amount of water in the suction control chamber

Answer 20

D. By the amount of water in the suction control chamber

Rationale: In a wet suction system, the amount of suction applied is determined by the amount of water in the suction control chamber. The water column controls the level of suction.

Question 21

A nurse is caring for a patient with a dry suction chest drainage system. Which of the following should the nurse assess to ensure the system is functioning properly?

A. The amount of water in the suction control chamber
B. The dial setting on the chest drainage unit
C. The water fluctuation in the water-seal chamber
D. The patient’s respiratory rate

Answer 21

B. The dial setting on the chest drainage unit

Rationale: In a dry suction system, the suction level is set by adjusting the dial on the chest drainage unit, not by the amount of water.

Question 22

A patient with a chest tube has a flutter valve in place. Which of the following is a benefit of using a flutter valve for pneumothorax management?

A. It allows for patient mobility.
B. It prevents all fluid drainage from the pleural space.
C. It provides continuous suction.
D. It prevents air from entering the pleural space during inspiration.

Answer 22

A. It allows for patient mobility.

Rationale: The flutter valve allows for mobility because it is small, enabling the patient to move around with minimal disruption. It prevents air from re-entering the pleural space during inspiration and allows air to vent during expiration.

Question 23

Which of the following is an important consideration when using a flutter valve for chest tube drainage?

A. The drainage bag must be vented to the atmosphere.

B. The chest tube should be clamped during ambulation.

C. The flutter valve must be placed in a water-seal chamber.

D. Suction pressure should be maintained at −40 cm H2O.

Answer 23

A. The drainage bag must be vented to the atmosphere.

Rationale: When using a flutter valve, the drainage bag must be vented to prevent the development of a tension pneumothorax. This is done by cutting a small slit in the top of the bag or using a bag with a built-in vent.

Question 24

A nurse is assessing a chest drainage system and notices that the suction control chamber is low on water. What should the nurse do?

A. Turn off the suction until the water level is restored.
B. Decrease the suction pressure to prevent damage.
C. Add more water to the suction control chamber.
D. Notify the provider immediately.

Answer 24

C. Add more water to the suction control chamber.

Rationale: In a wet suction system, the suction level is determined by the amount of water in the suction control chamber. The nurse should add more water as necessary to maintain proper suction.

Question 25

Which of the following is true regarding the use of a water-seal chamber in a chest drainage system?

A. It is used to provide continuous suction to the pleural space.
B. It contains water to create a one-way valve to prevent backflow of air.
C. It is where the patient’s drainage fluid is collected.
D. It is used to administer medications to the patient’s pleural space.

Answer 25

B. It contains water to create a one-way valve to prevent backflow of air.

Rationale: The water-seal chamber contains water that acts as a one-way valve, allowing air to exit but preventing air from re-entering the pleural space.

Question 26

A patient has a chest tube in place with a dry suction system. The nurse observes that the visual alert on the device is not indicating suction is working. What should the nurse do first?

A. Increase the suction pressure.
B. Notify the provider about the malfunction.
C. Replace the chest drainage unit.
D. Check the suction system for disconnections or blockages.

Answer 26

D. Check the suction system for disconnections or blockages.

Rationale: If the visual alert is not working, the nurse should first check the system for disconnections or blockages. Troubleshooting these issues is the most appropriate first step.

Question 27

When setting up a wet suction chest tube drainage system, what is the correct procedure for the suction control chamber?

A. Fill the suction control chamber to the 20-cm mark with sterile water.
B. Fill the suction control chamber to the 2-cm mark with sterile water.
C. Do not add any sterile water to the suction control chamber.
D. Fill the suction control chamber to the 5-cm mark with sterile water

Answer 27

A. Fill the suction control chamber to the 20-cm mark with sterile water.

Rationale: For a wet suction system, the suction control chamber should be filled to the ordered level, typically 20 cm H2O, to ensure proper suction pressure is applied.

Question 28

Which of the following is the nurse’s priority action during chest tube management when the drainage system is disconnected?

A. Clamp the chest tube to prevent air from entering the pleural space.

B. Reconnect the system and ensure the connections are secure.

C. Immerse the exposed end of the chest tube in sterile water to maintain the water-seal.

D. Monitor for respiratory distress and administer oxygen.

Answer 28

C. Immerse the exposed end of the chest tube in sterile water to maintain the water-seal.

Rationale: The priority action is to immediately immerse the exposed end of the chest tube in sterile water to re-establish the water-seal and prevent a tension pneumothorax.

Question 29

What is the correct way to prevent fluid from draining back into the pleural space when managing a chest drainage system?

A. Raise the drainage system to the level of the patient’s chest.

B. Position the tubing so that it is loosely coiled below the patient’s chest level.

C. Clamp the tubing to prevent any backflow.

D. Ensure the drainage system is placed above the patient’s chest to aid fluid removal.

Answer 29

B. Position the tubing so that it is loosely coiled below the patient’s chest level.

Rationale: To prevent backflow, the drainage system must be positioned below the patient’s chest level, ensuring gravity drainage and avoiding fluid from returning to the pleural space.

Question 30

A nurse is caring for a patient with a chest tube and notices clear yellow drainage in the first few hours. What is the nurse’s next action?

A. No action is needed as clear yellow drainage is normal.
B. Report the drainage to the healthcare provider (HCP) immediately.
C. Document the drainage as it is a normal finding.
D. Increase the suction pressure to hasten fluid drainage.

Answer 30

A. No action is needed as clear yellow drainage is normal.

Rationale: Clear yellow drainage is typically normal and indicates serous fluid. However, any significant changes in drainage color or amount should be reported to the HCP, especially if it becomes bloody or excessive.

Question 31

What should the nurse do if the chest tube drainage unit (CDU) is full?

A. Attempt to empty the drainage unit manually.
B. Leave the unit in place until it becomes more manageable.
C. Remove the chest tube and start a new drainage unit.
D. Replace the drainage unit immediately according to protocol.

Answer 31

D. Replace the drainage unit immediately according to protocol.

Rationale: The drainage unit should be replaced immediately when full. Do not attempt to empty it, as this can compromise the drainage system’s function.

Question 32

What is the purpose of using a petroleum gauze dressing around a chest tube insertion site?

A. To prevent infection at the site.
B. To provide a sterile barrier to prevent air leaks.
C. To allow air to escape from the pleural space.
D. To promote absorption of drainage at the insertion site.

Answer 32

B. To provide a sterile barrier to prevent air leaks.

Rationale: A petroleum gauze dressing is often used around the chest tube insertion site to create an airtight seal, preventing air from leaking into the pleural space.

Question 33

A nurse observes intermittent bubbling in the water-seal chamber of a chest tube drainage system. What is the most likely cause?

A. The lung is re-expanding.
B. The chest tube is obstructed.
C. The pleural space is still draining air.
D. The drainage system is disconnected.

Answer 33

C. The pleural space is still draining air.

Rationale: Intermittent bubbling indicates that air is still draining from the pleural space. This is common when a pneumothorax is present and resolves as the lung re-expands.

Question 34

What should the nurse do if no bubbling is observed in the suction control chamber of a wet suction system?

A. Increase the suction pressure to a higher level.
B. Refill the water-seal chamber.
C. Change the drainage system.
D. Assess if suction is turned on or if the pleural air leak is large.

Answer 34

D. Assess if suction is turned on or if the pleural air leak is large.

Rationale: If no bubbling is observed in the suction control chamber, the nurse should first check that suction is functioning and assess if the air leak is large enough to prevent bubbling.

Question 35

When preparing a dry suction chest tube drainage system, the nurse should:

A. Add sterile water to the suction control chamber.
B. Adjust the suction dial to the ordered suction level.
C. Increase the suction until continuous bubbling is visible in the water-seal chamber.
D. Attach the suction tubing to the collection chamber.

Answer 35

B. Adjust the suction dial to the ordered suction level.

Rationale: In a dry suction system, the suction level is controlled by adjusting the dial on the CDU to the ordered setting. There is no water in the suction chamber.

Question 36

Which of the following is a contraindication to milking or stripping the chest tube tubing?

A. It generates large changes in intrathoracic pressure, which can cause complications.
B. It helps to remove any clots or obstructions in the tubing.
C. It can prevent air leaks from re-entering the pleural space.
D. It helps to prevent the buildup of fluid in the drainage unit.

Answer 36

A. It generates large changes in intrathoracic pressure, which can cause complications.

Rationale: Milking or stripping chest tubes is no longer recommended because it can cause abrupt changes in intrathoracic pressure, potentially leading to complications such as tension pneumothorax.

Question 37

What should the nurse do to assess for subcutaneous emphysema at the chest tube insertion site?

A. Check for signs of infection like erythema and warmth.
B. Palpate the area for a “crackling” sensation under the skin.
C. Measure the drainage output from the chest tube.
D. Assess the patient’s oxygen saturation levels.

Answer 37

B. Palpate the area for a “crackling” sensation under the skin.

Rationale: Subcutaneous emphysema is identified by a “crackling” sensation when palpating the skin, caused by air leaking into the tissue around the chest tube insertion site.

Question 38

What is the recommended action if a patient with a chest tube experiences sudden pain and absent breath sounds on the affected side?

A. Administer analgesics and continue monitoring.
B. Clamp the chest tube to prevent further air leakage.
C. Assess for potential reaccumulation of air or fluid in the pleural space.
D. Increase the suction pressure immediately.

Answer 38

C. Assess for potential reaccumulation of air or fluid in the pleural space.

Rationale: Sudden pain and absent breath sounds could indicate that air or fluid is reaccumulating in the pleural space, which requires immediate assessment and possible intervention.

Question 39

When should a nurse replace the chest tube drainage unit (CDU)?

A. When the drainage volume exceeds 500 mL per hour.
B. When intermittent bubbling is no longer visible in the water-seal chamber.
C. When suction pressure is not maintaining proper airflow.
D. When the collection chamber becomes full and cannot be emptied.

Answer 39

D. When the collection chamber becomes full and cannot be emptied.

Rationale: The drainage unit should be replaced when the collection chamber is full. The unit should not be emptied manually.

Question 40

A nurse is caring for a patient with a chest tube and notices the water-seal chamber fluctuates (tidaling) with each breath. What does this indicate?

A. The chest tube is functioning properly.
B. The lung is fully re-expanded.
C. The drainage system is leaking.
D. There is a large air leak from the pleural space.

Answer 40

A. The chest tube is functioning properly.

Rationale: Tidaling in the water-seal chamber is normal and reflects changes in intrapleural pressure during the patient’s breathing. It indicates that the chest tube is functioning as intended.

Question 41

Which action is important when positioning the patient during chest tube insertion?

A. Place the patient in a supine position to minimize movement
A. Place the patient
B. Position the patient upright to allow for optimal lung expansion.
C. Keep the patient in a lateral position to facilitate drainage.
D. Position the patient with the affected side down to prevent complications.

Answer 41

B. Position the patient upright to allow for optimal lung expansion.

Rationale: Positioning the patient upright, or in a semi-Fowler’s position, helps with lung expansion, reduces the risk of complications, and facilitates the drainage of air and fluids from the pleural space.

Question 42

What action should the nurse take if the patient’s chest tube drainage system begins to exhibit continuous bubbling in the water-seal chamber after repositioning?

A. Clamp the chest tube to prevent further air from entering the pleural space.
B. Monitor the patient for signs of a pneumothorax.
C. Check the system for leaks and re-secure connections.
D. Decrease the suction pressure to stop the bubbling.

Answer 42

C. Check the system for leaks and re-secure connections.

Rationale: Continuous bubbling may indicate a leak in the system, which should be investigated. The nurse should ensure all connections are secure and assess for any air leaks before proceeding with further interventions.

Question 43

What should the nurse do if the chest tube drainage system is disconnected from the wall suction?

A. Immediately reconnect the system to the wall suction.
B. Disconnect the system from the patient.
C. Check for signs of a tension pneumothorax.
D. Remove the chest tube and replace it with a new one.

Answer 43

A. Immediately reconnect the system to the wall suction.

Rationale: If the chest tube system becomes disconnected from the wall suction, it should be promptly reconnected. Failure to do so may result in improper suction and ineffective drainage, compromising patient care.

Question 44

When performing a methodical assessment for an air leak, what is the correct action if clamping the chest tube at the patient’s chest stops the bubbling?

A. The leak is coming from the drainage system.
B. The system should be replaced immediately.
C. The leak is coming from the patient.
D. The suction pressure should be increased.

Answer 44

C. The leak is coming from the patient.

Rationale: If clamping the chest tube at the patient’s chest stops the bubbling, the air leak is coming from the patient, likely due to a leak at the insertion site or in the pleural space.

Question 45

What should be suspected when increased bubbling is noted in the water-seal chamber of a chest drainage system?

A. The drainage system is functioning normally.
B. The patient is developing atelectasis.
C. There may be an air leak in the drainage system or from the patient.
D. The suction pressure is too low.

Answer 45

C. There may be an air leak in the drainage system or from the patient.

Rationale: Increased bubbling indicates a possible air leak. The nurse should assess the system for leaks and check whether the patient has an air leak from the chest tube insertion site.

Question 46

What is the most important action when a chest tube becomes inadvertently disconnected from the patient?

A. Immediately reconnect the system to the suction source.
B. Place the distal end of the chest tube in sterile water to create an emergency water seal.
C. Clamp the chest tube to prevent air from entering the pleural space.
D. Notify the healthcare provider and wait for further instructions.

Answer 46

B. Place the distal end of the chest tube in sterile water to create an emergency water seal.

Rationale: If the chest tube becomes inadvertently disconnected from the patient, the immediate priority is to re-establish the water-seal system. The distal end of the chest tube should be placed in sterile water to prevent a tension pneumothorax until the system is properly reconnected.

Question 47

What is the initial nursing action if a chest tube drainage system is overturned?

A. Check for excessive bubbling in the water-seal chamber.
B. Replace the drainage unit immediately.
C. Clamp the chest tube to prevent air from entering the pleural space.
D. Return the drainage system to the upright position and encourage the patient to take deep breaths.

Answer 47

D. Return the drainage system to the upright position and encourage the patient to take deep breaths.

Rationale: If the drainage system is overturned and the water-seal is disrupted, it should be returned to an upright position. Encouraging the patient to take deep breaths helps to re-establish normal lung mechanics and prevent complications.

Question 48

What action should the nurse take when continuous bubbling is observed in the water-seal chamber of a chest tube drainage system?

A. Ensure the system is correctly attached and check for leaks.
B. Increase the suction pressure.
C. Clamp the chest tube immediately.
D. Increase the fluid level in the water-seal chamber.

Answer 48

A. Ensure the system is correctly attached and check for leaks.

Rationale: Continuous bubbling in the water-seal chamber suggests there may be an air leak in the system. The nurse should first ensure that the system is properly connected and check for any leaks. If the leak persists, further assessment is needed.

Question 49

Which of the following could be indicated if tidaling is absent in a spontaneously breathing patient with a chest tube?

A. The drainage system is functioning correctly.
B. The chest tube is not connected to the drainage system.
C. The lung has re-expanded.
D. The patient is in respiratory distress.

Answer 49

C. The lung has re-expanded.

Rationale: Absence of tidaling in a spontaneously breathing patient suggests that the lung has re-expanded, and there is no longer a change in intrapleural pressure during respiration. Other possible causes for absent tidaling include a blocked drainage system or connection to suction.

Question 50

Which of the following is the most appropriate nursing intervention before chest tube removal?

A. Provide a sedative to ensure the patient remains calm.

B. Administer pain medication 30 to 60 minutes prior to the procedure.

C. Ask the patient to cough deeply before the procedure.

D. Place the patient in a supine position and instruct them to remain still.

Answer 50

B. Administer pain medication 30 to 60 minutes prior to the procedure.

Rationale: Pain medication should be administered prior to chest tube removal to reduce discomfort. It is important to provide pain relief before the procedure to help ensure patient comfort during the removal process.

Question 51

What action is performed during chest tube removal to prevent air from entering the pleural space?

A. The site is immediately covered with an airtight, occlusive dressing.

B. The chest tube is removed while the patient exhales forcefully.

C. The patient is given supplemental oxygen after removal.

D. The dressing is applied with a non-occlusive bandage.

Answer 51

A. The site is immediately covered with an airtight, occlusive dressing.

Rationale: To prevent air from entering the pleural space after the chest tube is removed, an airtight, occlusive dressing is applied immediately. This ensures that the pleura seals off and helps prevent a pneumothorax.

Question 52

What is the purpose of performing a chest x-ray 30 to 60 minutes after chest tube removal?

A. To check for the presence of infection at the insertion site.
B. To evaluate lung compliance.
C. To monitor for drainage from the wound site.
D. To assess for pneumothorax or fluid accumulation.

Answer 52

D. To assess for pneumothorax or fluid accumulation.

Rationale: A chest x-ray is done post-removal to check for any complications such as pneumothorax (air in the pleural space) or fluid accumulation. This is an important diagnostic step to ensure the patient is healing properly after the chest tube removal.

Question 53

Which of the following signs should the nurse immediately report to the healthcare provider after chest tube removal?

A. Mild redness around the wound site.
B. Decreased breath sounds on the side of the chest tube removal.
C. Respiratory distress.
D. Low-grade fever.

Answer 53

C. Respiratory distress.

Rationale: Respiratory distress after chest tube removal may indicate a recurrence of the original problem, such as pneumothorax or fluid accumulation. This should be immediately reported to the healthcare provider for further evaluation and intervention.

Question 54

What is the most important reason for applying a petroleum gauze dressing over the chest tube insertion site after removal?

A. To prevent infection at the site.
B. To promote drainage from the pleural space.
C. To prevent air from entering the pleural space.
D. To absorb any blood or fluid from the site.

Answer 54

C. To prevent air from entering the pleural space.

Rationale: The petroleum gauze dressing is applied to the chest tube insertion site to create an airtight seal, preventing air from entering the pleural space and ensuring that the pleura heals without complications, such as pneumothorax.

Question 55

A postoperative patient has a right-sided pleural chest tube connected to a chest drainage device. There is continuous bubbling in the suction-control chamber of thewet-suction collection device. Which action would the nurse take?

a. Adjust the dial on the wall regulator.

b. Continue to monitor the collection device.

c. Document the presence of a large air leak.

d. Notify the surgeon of a possible pneumothorax.

Answer 55

b. Continue to monitor the collection device.

Rationale: Continuous bubbling is expected in the suction-control chamber of a wet-suction device and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction pressure. the amount of suction applied is regulated by the amount of water in this chamber and not by the amount of suction applied to the system.

Question 56

The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action could the nurse delegate to the assistive personnel (AP)?

a. Document the amount of drainage every 8 hours.

b. Obtain samples of drainage for culture from the system.

c. Assess patient pain level associated with the chest tube.

d. Check the water-seal chamber for the correct fluid level.

Answer 56

a. Document the amount of drainage every 8 hours.

Rationale: AP education includes documentation of intake and output. the other actions are within the scope of practice and education of licensed nursing personnel.