Quiz #2 Respiratory Flashcards
Hemothorax
DuLL resonance
Filled with blood or fluid
A nurse is collecting data from a client who has a right hemothorax and a water-seal chest tube drainage system to closed suction. For which of the following findings should the nurse contact the charge nurse?
A. Serosanguineous drainage in the collection chamber measures 50 mL in the last hour.
B. Fluid in the water seal chamber fluctuates with the client’s respirations.
C. Subcutaneous emphysema is present on the client’s right chest wall.
D. Diminished breath sounds noted to the right lower lobe over the past two days.
C. Subcutaneous emphysema is present on the client’s right chest wall.
It can indicate that there is a significant air leak from the lung or chest tube system, which can compromise the effectiveness of the chest tube drainage system in re-expanding the lung and managing the hemothorax.
Pneumothorax
Accumulation of air in pleural space
Hyperresonance —> High air (tapping on hollow drum or tree)
A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?
A. Crepitus in the area above and surrounding the insertion site
B. Bubbling of the water in the water seal chamber with exhalation
C. Eyelets are not visible
D. Movement of the trachea toward the unaffected side
D. Movement of the trachea toward the unaffected side
This is correct because movement of the trachea toward the unaffected side is a serious finding that indicates a tension pneumothorax, which is a life-threatening condition that occurs when air accumulates in the pleural space and causes pressure on the mediastinum. can lead to cardiogenic shock The nurse should notify the provider immediately and prepare for needle decompression or chest tube insertion.
Pneumothorax anticipated actions
ABG
Chest tube
IV insertion
A nurse is caring for a 75 year old male client who is experiencing difficulty breathing and shortness of breath.
The nurse is caring for the client following a thoracentesis.
(Select the 3 findings that require immediate follow up)
Decreased lung sounds
Heart rate 110/ min and regular
Oxygen saturation of 95%
Subcutaneous emphysema
Trachea midline
Puncture site dry
Decreased lung sounds
Heart rate 110/ min and regular
Subcutaneous emphysema
A nurse is caring for a client who has a pneumothorax. Which prescriptions should the nurse anticipate for a client who has a pneumothorax? Specify whether it’s anticipated, nonessential, or contraindicated.
A. Anticipated
- Obtain ABGs
- prepare for insertion of a Chest Tube
- Obtain IV access
B. Nonessential
- Pulmonary function test
- Computed tomography (CT) scan of the chest
C. Contraindicated
- Thoracentesis
A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take?
(a) Position the client in an upright position, leaning over the bedside table.
(b) Explain the procedure.
(c) Obtain ABGs.
(d) Administer benzocaine spray.
(a) Position the client in an upright position, leaning over the bedside table.
This widens the intercostal space for the provider to access the pleural fluid. It is the responsibility of the provider, not the nurse, to explain the procedure. It is not indicated that the client needs ABGs drawn. Benzocaine spray is administered for a bronchoscopy, not a thoracentesis.
Change of shift nurse priority
Patient experiencing tracheal deviation
- pressure increases in chest cavity
- indicative of tension pneumothorax
A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take?
A. Increase the client’s wall suction.
B. Reposition the client.
C. Clamp the client’s chest tube.
D. Strip the client’s chest tube.
B. Reposition the client.
Repositioning the client is the appropriate action for the nurse to take, as chest burning may indicate that the chest tube is kinked, twisted, or compressed, which can impair drainage and ventilation.
Pleural effusion manifestation
Dullness on percussion
A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?
A. Disconnect the chest tube from the drainage system during transport.
B. Empty the collection chamber prior to transport.
C. Clamp the chest tube prior to transferring the client to a wheelchair.
D. Keep the drainage system below the level of the client’s chest at all times.
Keep the drainage system below the level of the client’s chest at all times.
During transport, the drainage system should be kept below the level of the client’s chest to prevent air and drainage fluid from re-entering the thoracic cavity.
A nurse is caring for a client who is 12 hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations?
A. Constant bubbling in the suction-control chamber.
B. Continuous bubbling in the water-seal chamber.
C. Bloody drainage in the collection chamber.
D. Fluid-level fluctuations in the water-seal chamber.
B. Continuous bubbling in the water-seal chamber.
Continuous bubbling usually suggests that there is a leak somewhere in the system. This could be due to an open connection, a loose seal, or an issue with the chest tube insertion site.
Chest tube indications
Treatment of hemothorax, pneumothorax, and tension pneumothorax
*can suck out air, fluid, and blood in pleural space
3 chambers
- suction chamber
- water-seal chamber
- collection chamber
Suction chamber
Slow, gentle, continuous bubbling
