Upgrade to remove ads Show
Only ₩37,125/year
Terms in this set (43)A 5-year-old child is returned to the pediatric intensive care unit after cardiac surgery. The child has a left chest tube attached to water-seal drainage, an intravenous line running of D5½NS at 4 mL/hr, and a double-lumen nasogastric tube connected to continuous suction. A cardiac monitor is in place, as is a dressing on the left
side of the chest dressing. What is the priority nursing intervention? 1Auscultating breath sounds An infant who underwent open repair of a fractured sternum now has a chest tube. What should the nurse explain to the parents concerning the chest tube? The infant will not feel any discomfort. It is inserted to drain the chest cavity of air. A client is admitted to the postanesthesia care unit after a segmental resection of the right lower lobe of the lung. A chest tube drainage system is in place. When caring for this tube, what should the nurse do? Raise the drainage system to bed level and check its patency. Mark the time and fluid level on the side of the drainage chamber A client has a chest tube for a pneumothorax. The nurse finds the client in respiratory difficulty, with the chest tube separated from the drainage system. What should the nurse do? Obtain a new sterile drainage system. Reconnect the client's tube to the drainage system.
The parents of a child who is scheduled for open-heart surgery ask why their child must be subjected to chest tubes after surgery. What should the nurse consider before responding in language that the parents will understand? They will increase tidal volume. Drainage of air and fluid will be facilitated. A client has chest tubes attached to a chest tube drainage system. What should the nurse do when caring for this client? Clamp the chest tubes when suctioning. Palpate the surrounding area for crepitus. A chest tube is inserted into a client who was stabbed in the chest and is attached to a closed-drainage system. Which is an important nursing intervention when caring for this client? Observe for fluid fluctuations in the water-seal chamber.
Observe for fluid fluctuations in the water-seal chamber. During the first 24 hours after open-heart surgery, serosanguineous fluid drains from the client's chest tube. How much drainage should the nurse expect during this period? 100 to 300 mL 400 to 500 mL During the first 36 hours after the insertion of chest tubes, when assessing the function of a three-chamber, closed-chest drainage system, the nurse identifies that the water in the underwater seal tube is not fluctuating. What initial action should the nurse take? Take the client's vital signs. Check the tube to ensure that it is not kinked. A client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department chest tubes are inserted, one in the second intercostal space and one at the base of the lung. What does the nurse expect the tube in the second intercostal space to accomplish? Remove the air that is present in the intrapleural space Remove the air that is present in the intrapleural space A nurse is caring for a client with a pneumothorax that has a chest tube attached to a closed chest drainage system. If the chest tube and closed-chest drainage system are effective, the type of pressure that will be reestablished is:
Neutral pressure in the pleural space Negative pressure in the pleural space The nurse is caring for a client after the client's open heart surgery (CABG). Serosanguineous fluid drains from the client's chest tube. The nurse expects what volume of drainage from the tube
during the first 24 hours after the surgery? 400 to 500 mL A client who sustained trauma to the chest as a result of an injury has chest tubes inserted and is attached to a closed-chest drainage system. When caring for this client, the nurse should: Palpate the area around the tubes for crepitus Palpate the area around the tubes for crepitus To evaluate the effectiveness of a chest tube inserted in a client with a pneumothorax, the nurse assesses for: Productive coughing Return of breath sounds A client with a spontaneous pneumothorax asks, "Why did they put this tube into my chest?" The nurse explains that the purpose of the chest tube is to: Check for bleeding in the lung Remove air from the pleural space The nurse is providing postoperative care to a client with cancer of the lung that had a lobectomy. The client has a chest tube attached to suction. Which assessment finding includes a complication? Clots in the tubing during the first postoperative day Subcutaneous emphysema on the second postoperative day A client has a chest tube inserted to treat a right hemopneumothorax. In which position should the nurse place the client to facilitate chest drainage? Supine Right side-lying A nurse is providing immediate postoperative care to a client that had a lung resection for a malignancy. The client has a closed chest tube drainage system connected to suction. Which assessment finding requires additional evaluation by the nurse? A column of water 20 cm high in the suction control chamber Constant bubbling in the water seal chamber A client tells the nurse that the client's chest tube is scheduled to be removed soon. Before it is removed, the nurse is aware that: The drainage system will be disconnected from the chest tube. A chest x-ray will be performed to determine lung re-expansion. The primary responsibility of a nurse when caring for a client with a chest tube attached to a three-chamber underwater-seal drainage system is to: Ensure maintenance of the closed system Ensure maintenance of the closed system A client's chest tube has accidentally dislodged. What is the nursing action of highest priority? Place the client in a left side-lying position. Apply a petroleum gauze dressing over the site. The nurse is developing a plan of care for a client that had a chest tube removed. To promote respiratory exchange, the plan should include: Careful monitoring for crepitus Coughing and deep breathing every hour A client has a chest tube for a pneumothorax. The nurse discovers that the chest tube has become disconnected from the drainage system, and the client is experiencing respiratory difficulty. What initial action should the nurse take? Obtain a new sterile drainage system Reconnect the client's tube to the drainage system A nurse is caring for a client who experienced a crushing chest injury. A chest tube is inserted. Which observation indicates a desired response to this treatment? Increased breath sounds Increased breath sounds After thoracic surgery a client has a chest tube connected to a water-seal drainage system that is attached to suction. When excessive bubbling is observed in the water-seal chamber, the nurse should: Strip the chest tube catheter Check the system for air leaks A client has a closed chest drainage system in place. To determine the amount of chest tube drainage, the nurse should: Refer to the date and time markings on the outside of the collection chamber Refer to the date and time markings on the outside of the collection chamber A client with a pneumothorax has a chest tube inserted and attached to a closed-chest drainage system. The client asks, "Why is the tube in my chest hooked up to a contraption with water in it?" The nurse explains that the water: Promotes pleural drainage via gravity Prevents reflux of air back into the chest A client is admitted to the hospital for a surgical resection of the lower left lobe of the lung. After surgery the client has a chest tube to a closed-chest drainage system. What should the nurse do to determine if the chest tube is patent? Milk the chest tube toward the drainage unit Observe for fluctuations of the fluid in the water-seal chamber A client who sustained chest trauma in an accident has bilateral chest tubes inserted. What is the nurse's primary responsibility when caring for this client? Maintaining a closed system Maintaining a closed system The nurse is caring for a client who had a wedge resection of a lobe of the lung and now has a chest tube with a three-chamber underwater drainage system in place. The nurse considers that the main purpose of the third chamber of the underwater drainage system is to: Act as a drainage
container Control the amount of suction While walking in a hallway, a client with a chest tube becomes confused and pulls the chest tube out. What is the nurse's immediate action? Place the client in the supine position Cover the opening with the cleanest material available A client is scheduled for coronary artery bypass surgery. The nurse explains to the client that chest tubes will be inserted during surgery to: Prevent atelectasis postoperatively Reestablish negative intrapleural pressure A client sustains a stab wound to the chest, and a chest tube is inserted. Later the client's chest tube appears to be obstructed. What is the most appropriate nursing action? Instruct the client to cough. Instruct the client to cough. A nurse is caring for a client with a pneumothorax who has a chest tube in place. What should the nurse do when caring for this client? Encourage range of motion to the client's arm on the affected side. Encourage range of motion to the client's arm on the affected side. A nurse is caring for a client who has chest tubes inserted to treat a hemothorax that resulted from a crushing chest injury. A commonality of the various stationary chest tube drainage systems is that the first chamber is designed to: Collect drainage Collect drainage A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who develops a pneumothorax and has a chest tube inserted. What is the primary purpose of the chest tube? Lessens the client's chest discomfort Restores negative pressure in the pleural space A nurse is caring for a client with a pneumothorax who has a chest tube in place with a closed drainage system. Which of these actions by the nurse is correct? Strip the chest tube periodically. Keep the drainage system lower than the level of the client's chest An infant who was in a motor vehicle collision has undergone open repair of a fractured sternum and now has a chest tube. What should the nurse explain to the infant's parents about the chest tube? "The tube doesn't cause discomfort. It's been put in place for emergency use." "The tube will be taken out once your baby is stable and oral feedings are started." "The tube has been placed to drain the air that entered the chest cavity during surgery." "The tube drains the air that accumulated in your baby's chest after the lung was punctured." "The tube has been placed to drain the air that entered the chest cavity during surgery." A client who had thoracic surgery is admitted to the postanesthesia care unit. What should the nurse do after the chest tube is attached to a disposable plastic waterseal drainage system? Ensure the security of the connections from the client to the drainage unit. Ensure the security of the connections from the client to the drainage unit. A client with a chest tube is to be transported via a stretcher. When transporting the client, the nurse should keep the: Collection device attached to mechanical suction. Chest tube clamped distal to the water-seal chamber. Collection device below the level of the client's chest. Chest tube end covered with sterile gauze pads taped to the client Collection device below the level of the client's chest A nurse is caring for a client with a chest tube. How will complete lung expansion be determined before removal of the chest tube? Return of usual tidal volume Comparison of chest radiographs Immediately after a thoracentesis, a client's right lung collapses. A chest tube is inserted and is attached to a three-chamber closed drainage system. What does the nurse assess about the fluid when the chest tube is functioning properly? Remains constant in the chest drainage chamber. Is bubbling gently in the chest drainage chamber. Is bubbling vigorously in the suction control chamber. Rises in the tube of the water seal chamber during inspiration Rises in the tube of the water seal chamber during inspiration How should the nurse monitor for the complication of subcutaneous emphysema after the insertion of chest tubes? Palpate around the tube insertion sites for crepitus. Palpate around the tube insertion sites for crepitus. Sets with similar termsATI MED-SURG: CH 18 Chest Tube Insertion and Monit…17 terms nmbulger3 NURSING SKILLS CHEST TUBES29 terms stephdknsn ATI Chapter 18 Chest Tube Insertion and Monitoring23 terms delinates Med/Surg ATI Ch 18 Chest Tube insertion and monito…27 terms Rainer230 Sets found in the same folderexam 4 adaptive questions117 terms Trian_Humper respiratory evolve24 terms judy_liu66 Chest Tubes85 terms renee_berryrissman EVOLVE QUIZ ON DIABETES82 terms pampa11 Other sets by this creatorNCLEX Review180 terms kiana216 Fundamentals82 terms kiana216 Hesi #263 terms kiana216 Nursing - 309 Advanced Skills267 terms kiana216 Other Quizlet setsExam 1 Material120 terms rinaapatell Chapter 5 study exercises20 terms katharina_pribil Part 2 Study notes definitions HLSC12015 terms smile_will_u QZ Ch 21 Quiz flexible budget & Std costs13 terms Fry__Blake3 Related questionsQUESTION The nurse administers lisinopril [Prinivil] to a hypertensive patient with heart failure. Which parameter should the nurse evaluate to determine the therapeutic effectiveness of lisinopril [Prinivil] in this patient? 4 answers QUESTION What is the most common congenital deformities in the US 15 answers QUESTION A nurse teaches a client who is prescribed an insulin pump. Which statement should the nurse include in this clients discharge education? 10 answers QUESTION A patients phosphorus is 5.9. He is placed on phosphorus binders. What instructions should he be given regarding phosphate binders? 15 answers What should the nurse do if a chest tube is accidentally pulled out?In an unplanned chest-tube removal, stay calm. With a gloved hand, immediately cover the open insertion site and call for help while staying with the patient. Ask for petroleum gauze to cover the site, along with dry gauze and tape to complete the dressing.
Which immediate action should a nurse take if a client's chest tube is accidentally disconnected from the disposable water seal system?If the chest tubing becomes disconnected, the nurse should immediately place a gauze dressing over the site. An occlusive dressing can also be necessary to prevent the redevelopment of a pneumothorax.
What are priority nursing interventions for a client with a chest tube?Never lift drain above chest level. Never lift drain above chest level.. The unit and all tubing should be below patient's chest level to facilitate drainage.. Tubing should have no kinks or obstructions that may inhibit drainage.. Ensure all connections between chest tubes and drainage unit are tight and secure.. What happens if a chest tube becomes disconnected?What if the chest tube becomes disconnected? If the tubing becomes disconnected, most institutions' policies indicate for you to quickly insert the patient end of the tubing 1-2 inches into the bottle of sterile water to create a water seal while you get a new system set up. Easy!
|
Which nursing action is of highest priority when a clients chest tube has accidentally dislodged?
zusammenhängende Posts
Urheberrechte © © 2024 ketiadaan Inc.
