NRS 461 Chest Tube & Trauma questions LATEST UPDATE

NRS 461 Chest Tube & Trauma questions LATEST UPDATE A patient is admitted to the hospital with injuries from a motor vehicle crash. During the nurse’s initial assessment, the patient develops hypotension and severe jugular distension with a tracheal deviation. What should the nurse suspect is occurring in this patient? a. Tension pneumothorax b. Hemorrhage c. Compensatory shock d. Hypovolemic shock 2. A patient is admitted with a diagnosis of blunt trauma to the abdomen after a motor vehicle crash. What should the nurse assess first when the patient arrives in the emergency department? a. airway for patency b. abdomen for any abnormalities c. cervical spine for tenderness d. signs of neurological deficits 3. The nurse is assessing a patient recovering from a motor vehicle crash. Which assessment finding indicates that the patient is experiencing a pneumothorax? a. hyperresonance to percussion at the apex of the left lung b. dullness to percussion at the base of the left lung c. crackles throughout the left lung d. shallow breathing 4. A 20-year-old patient who is asking questions about smoking cessation tells the nurse about an upcoming class on scuba diving. The nurse recognizes that this patient might be at risk for developing what health problem? a. pleural effusion b. pleurisy c. pneumothorax d. hemothorax 5. The nurse is caring for a patient on mechanical ventilation with positive end expiratory pressure (PEEP). When assessing the patient, which finding would indicate the possibility of tension pneumothorax? a. New onset of absent breath sounds b. blood pressure of 170/80 c. pulse oximetry readings ranging from 94% to 96% d. crackles and wheezing heard in both lungs 6. A patient is diagnosed with a tension pneumothorax. What should the nurse expect to assess in this patient? Select all that apply. a. Hypertension b. distended neck veins This study source was downloaded by from CourseH on :00:07 GMT -05:00 c. bradycardia d. absent breath sounds on the affected side e. tracheal deviation toward unaffected side 7. The nurse observes air bubbles in a patient’s chest tube water seal chamber. How should the nurse interpret this finding? a. normal b. an emergency c. an indication that the pneumothorax is worsening d. an indication to remove the chest tube 8. A patient has a chest tube inserted for a pneumothorax. What should the nurse expect when assessing the drainage system? a. periodic bubbling in the water seal chamber immediately after insertion b. No evidence of tidaling c. Vigorous bubbling in the suction control chamber d. Large amount of bloody drainage in the drainage collection chamber 9. During the assessment of a patient’s respiratory status, the nurse notes paradoxical lung movements. This finding is consistent with what health problem? a. flail chest b. pleurisy c. pneumothorax d. pneumonia 10. The client is admitted to the emergency department with chest trauma. Which signs/symptoms indicate to the nurse the diagnosis of pneumothorax? a. Bronchovesicular lung sounds and bradypnea. b. Unequal lung expansion and dyspnea. c. Frothy, bloody sputum and consolidation. d. Barrel chest and polycythemia. 11. The client had a right-sided chest tube inserted two (2) hours ago for a pneumothorax. Which action should the nurse implement if there is no fluctuation (tidaling) in the water-seal compartment? a. Obtain an order for a STAT chest x-ray. b. Increase the amount of wall suction. c. Check the tubing for kinks or clots. d. Monitor the client’s pulse oximeter reading. 12. Which intervention should the nurse implement for a male client who has had a leftsided chest tube for six (6) hours and who refuses to take deep breaths because of the pain? a. Medicate the client and have the client take deep breaths. This study source was downloaded by from CourseH on :00:07 GMT -05:00 b. Encourage the client to take shallow breaths to help with the pain. c. Explain deep breaths do not have to be taken at this time d. Tell the client if he doesn’t take deep breaths, he could die 13. The unlicensed assistive personnel (UAP) assist the client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention from the nurse? a. The UAP keeps the chest tube below chest level. b. The UAP has the chest tube attached to suction. c. The UAP allowed the client out of the bed. d. The UAP uses a bedside commode for the client. 14. The nurse is caring for a client with a right-sided chest tube that is accidentally pulled out of the pleural space. Which action should the nurse implement first? a. Notify the health-care provider to have chest tubes reinserted STAT. b. Instruct the client to take slow shallow breaths until the tube is reinserted. c. Take no action and assess the client’s respiratory status every 15 minutes. d. Tape a petroleum jelly occlusive dressing on 3 sides on the incisions site 15. The nurse is presenting a class on chest tubes. Which statement best describes a tension pneumothorax? a. A tension pneumothorax develops when an air-filled bleb on the surface of the lung ruptures. b. When a tension pneumothorax occurs, the air moves freely between the pleural space and the atmosphere. c. The injury allows air into the pleural space but prevents it from escaping from the pleural space. d. A tension pneumothorax results from a puncture of the pleura during a central line placement. 16. Which action should the nurse implement for the client with a hemothorax who has a right-sided chest tube with excessive bubbling in the water-seal compartment? a. Check the amount of wall suction being applied. b. Assess the tubing for any blood clots. c. Milk the tubing proximal to distal. d. Encourage the client to cough forcefully. 17. Which assessment data indicate to the nurse the chest tubes inserted three (3) days ago have been effective in treating the client with a hemothorax? a. Gentle bubbling in the suction compartment. b. No fluctuation (tidaling) in the water-seal compartment. c. The drainage compartment has 250 mL of blood d. The client is able to deep breathe without any pain. This study source was downloaded by from CourseH on :00:07 GMT -05:00 18. The nurse is caring for a client with a right-sided chest tube secondary to a pneumothorax. Which interventions should the nurse implement when caring for this client? Select all that apply. a. Place the client in the low Fowler’s position. b. Assess chest tube drainage system frequently. c. Maintain strict bedrest for the client. d. Secure a loop of drainage tubing to the sheet e. Observe the site for subcutaneous emphysema 19. The charge nurse is making client assignments on a medical floor. Which client should the charge nurse assign to the licensed practical nurse (LPN)? a. The client with pneumonia who has a pulse oximeter reading of 91%. b. The client with a hemothorax who has Hb of 9 g/dL and Hct of 20%. c. The client with chest tubes who has jugular vein distention and BP of 96/60. d. The client who is two (2) hours post–bronchoscopy procedure. 20. The alert and oriented client is diagnosed with a spontaneous pneumothorax, and the health care provider is preparing to insert a left-sided chest tube. Which intervention should the nurse implement first? a. Gather the needed supplies for the procedure. b. Obtain a signed informed consent form. c. Assist the client into a side-lying position. d. Discuss the procedure with the client. 21. Which intervention should the nurse implement first for the client diagnosed with a hemothorax who has had a right-sided chest tube for three (3) days and has no fluctuation (tidaling) in the water compartment? a. Assess the client’s bilateral lung sounds. b. Obtain an order for a STAT chest x-ray. c. Notify the health-care provider as soon as possible. d. Document the findings in the client’s chart. 22. You are providing care to a patient with a chest tube. On assessment of the drainage system, you note continuous bubbling in the water seal chamber and oscillation. Which of the following is the CORRECT nursing intervention for this type of finding? a. Reposition the patient because the tubing is kinked. b. Continue to monitor the drainage system. c. Increase the suction to the drainage system until the bubbling stops. d. Check the drainage system for an air leak 23. A patient is receiving positive pressure mechanical ventilation and has a chest tube. When assessing the water seal chamber what do you expect to find? a. The water in the chamber will increase during inspiration and decrease during expiration. This study source was downloaded by from CourseH on :00:07 GMT -05:00 b. There will be continuous bubbling noted in the chamber. c. The water in the chamber will decrease during inspiration and increase during expiration. d. The water in the chamber will not move. 24. What type of chest tube system does this statement describe? This chest drainage system has no water column to control suction but uses a suction monitor bellow that balances the wall suction, and you can adjust water suction pressure using the rotary suction dial on the side of the system. It allows for higher suction pressure levels, has no bubbling sounds, and water does not evaporate from it as with other systems. a. Mediastinal chest tube system b. Dry suction chest tube system c. Wet suction chest tube system d. Dry-Wet suction chest tube system 25. The patient in room 2569 calls on the call light to tell you something is wrong with his chest tube. When you arrive to the room you note that the drainage system has fallen on its side and is leaking drainage onto the floor from a crack in the system. What is your next PRIORITY? a. Place the patient in supine position and clamp the tubing. b. Notify the physician immediately. c. Disconnect the drainage system and get a new one. d. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system. 26. You're assessing a patient who is post-opt from a chest tube insertion. On assessment, you note there is 50 cc of serosanguinous fluid in the drainage chamber, fluctuation of water in the water seal chamber when the patient breathes in and out and bubbling in the suction control chamber. Which of the following is the most appropriate nursing intervention? a. Document your findings as normal. b. Assess for an air leak due to bubbling noted in the suction chamber. c. Notify the physician about the drainage. d. Milk the tubing to ensure patency of the tubes. 27. A patient is recovering from a pneumothorax and has a chest tube present. Which of the following is an appropriate finding when assessing the chest tube drainage system? a. Intermittent bubbling may be noted in the water seal chamber. b. 200 cc of drainage per hour is expected during recovery of a pneumothorax. c. The chest tube is positioned at the patient's chest level to facilitate drainage. d. All of these options are appropriate findings 28. While helping a patient with a chest tube reposition in the bed, the chest tube becomes dislodged. What is your immediate nursing intervention? This study source was downloaded by from CourseH on :00:07 GMT -05:00 a. Stay with the patient and monitor their vital signs while another nurse notifies the physician. b. Place a sterile dressing over the site and tape it on three sides and notify the physician. c. Attempt to re-insert the tube. d. Keep the site open to air and notify the physician. 29. A patient is about to have their chest tube removed by the physician. As the nurse assisting with the removal, which of the following actions will you perform? Select-allthat-apply: a. Educate the patient how to take a deep breath out and inhale rapidly while the tube in being removed. b. Gather supplies needed which will include a petroleum gauze dressing per physician preference. c. Place the patient in Semi-Fowler's position. d. Have the patient take a deep breath, exhale, and bear down during removal of the tube. e. Pre-medicate prior to removal as ordered by the physician. f. Place the patient is prone position after removal. 30. A patient with a chest tube has no fluctuation of water in the water seal chamber. What could be the cause of this? a. This is an expected finding. b. The lung may have re-expanded or there is a kink in the system. c. The system is broken and needs to be replaced. d. There is an air leak in the tubing. 31. The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial nursing action should the nurse take? a. Call the health care provider b. Place the tube in a bottle of sterile water c. Immediately replace the chest tube system d. Place a sterile dressing over the disconnection site 32. While preparing the patient for a chest tube insertion, the nurse should perform all of the following except: a. Make sure the patient has given informed consent b. Explain to the patient that a local anesthetic will reduce discomfort c. Reinforce the practitioner’s explanation of the procedure with the patient and their family d. Express the need to keep the drainage system at chest level This study source was downloaded by from CourseH on :00:07 GMT -05:00 Chest Trauma 1. A 2. A 3. A 4. C 5. A 6. B, D, E 7. A 8. A 9. A 10. B 11. C 12. A 13. B 14. D 15. C 16. A 17. B 18. B, D, E 19. D 20. B 21. A Chest Tubes Starts 22. D 23. C 24. B 25. D 26. A 27. A 28. B 29. B, C, D, E 30. B 31. B 32. D This study source was downloaded by from CourseH on :00:0