Shock information (ATI Material); Advanced Nursing Concepts: Test
2 | QUESTIONS AND ANSWERS | 2025/2026
Terms in this set (203)
into the pleural space to drain fluid, blood, or air; reestablish
where are chest tubes inserted
a negative pressure; facilitate lung expansion; and restore
and why
normal intrapleural pressure
where is chest tube insertion in the ED, at client's bedside, or in the operating room through a
usually performed thoracotomy incision
when are chest tubes removed when the lungs have reexpanded and/or there is no more fluid
drainage
-a disposable three-chamber drainage system (often used)
--first chamber: drainage collection
what types of chest tube systems
--second chamber: water seal
are there
--third chamber: suction control
how are water seals created by adding sterile fluid to a chamber up to the 2 cm line.
it allows air to exit from the pleural space on exhalation and
what is a water seal for
stops air from entering with inhalation
the chamber must be kept upright and below the chest tube insertion
how do you maintain the water site at all times
,seal ** nurse should routinely monitor the water level due to the
possibility of evaporation. The nurse should add fluid as
needed to maintain the 2 cm water seal level
-the height of the sterile fluid in the suction control chamber
what determines the amount ** a suction pressure of -20 cm H2O is common
of suction transmitted to the -the application suction results in continuous bubbling in the suction
pleural space and what does chamber
the suction result in
** the nurse should monitor the fluid level and add fluid as
needed to maintain the prescribed level of suctioning
movement of the fluid level with respiration and it is
expected in the water seal chamber
what is tidaling -with spontaneous respirations, the fluid level will rise with
inspiration ((increase in negative pressure in lung) and will
fall with expiration
what does cessation of tidaling lung reexpansion or an obstruction within the system
in the water seal chamber
signal
, -pnemothorax (collapsed lung)
-hemothorax (blood in lung)
what are indicactions for a chest -postoperative chest drainage (thoracotomy or open heart surgery)
tube -pleural effusion (fluid in the lungs)
-lung abcess (necrotic lung tissue)
space on outside of lung
what is pleural space
-dyspnea
-distended neck vein (due to fluid backing up)
what symptoms does the
-poor circulation
client usually present with
-cough
when needing chest tube
-absent or reduced breath sounds
what is desired position for a supine or semifowlers
chest tube insertion
how is the chest tube tip - up toward shoulder
positioned for a pneumothorax -down toward the posterior
and a hemothorax or pleural
effusion
-vital signs, breath sounds, SaO2, color, and respiratory effort
after chest tube insertion,
as indicated by the status of the client
what should the nurse
-at least every 4 hours
assess for and how often
what should you encourage a -cough and deep breath
client to do after chest tube -every 2 hours
and how often
-check the water seal level every 2 hours, and add fluid as
2 | QUESTIONS AND ANSWERS | 2025/2026
Terms in this set (203)
into the pleural space to drain fluid, blood, or air; reestablish
where are chest tubes inserted
a negative pressure; facilitate lung expansion; and restore
and why
normal intrapleural pressure
where is chest tube insertion in the ED, at client's bedside, or in the operating room through a
usually performed thoracotomy incision
when are chest tubes removed when the lungs have reexpanded and/or there is no more fluid
drainage
-a disposable three-chamber drainage system (often used)
--first chamber: drainage collection
what types of chest tube systems
--second chamber: water seal
are there
--third chamber: suction control
how are water seals created by adding sterile fluid to a chamber up to the 2 cm line.
it allows air to exit from the pleural space on exhalation and
what is a water seal for
stops air from entering with inhalation
the chamber must be kept upright and below the chest tube insertion
how do you maintain the water site at all times
,seal ** nurse should routinely monitor the water level due to the
possibility of evaporation. The nurse should add fluid as
needed to maintain the 2 cm water seal level
-the height of the sterile fluid in the suction control chamber
what determines the amount ** a suction pressure of -20 cm H2O is common
of suction transmitted to the -the application suction results in continuous bubbling in the suction
pleural space and what does chamber
the suction result in
** the nurse should monitor the fluid level and add fluid as
needed to maintain the prescribed level of suctioning
movement of the fluid level with respiration and it is
expected in the water seal chamber
what is tidaling -with spontaneous respirations, the fluid level will rise with
inspiration ((increase in negative pressure in lung) and will
fall with expiration
what does cessation of tidaling lung reexpansion or an obstruction within the system
in the water seal chamber
signal
, -pnemothorax (collapsed lung)
-hemothorax (blood in lung)
what are indicactions for a chest -postoperative chest drainage (thoracotomy or open heart surgery)
tube -pleural effusion (fluid in the lungs)
-lung abcess (necrotic lung tissue)
space on outside of lung
what is pleural space
-dyspnea
-distended neck vein (due to fluid backing up)
what symptoms does the
-poor circulation
client usually present with
-cough
when needing chest tube
-absent or reduced breath sounds
what is desired position for a supine or semifowlers
chest tube insertion
how is the chest tube tip - up toward shoulder
positioned for a pneumothorax -down toward the posterior
and a hemothorax or pleural
effusion
-vital signs, breath sounds, SaO2, color, and respiratory effort
after chest tube insertion,
as indicated by the status of the client
what should the nurse
-at least every 4 hours
assess for and how often
what should you encourage a -cough and deep breath
client to do after chest tube -every 2 hours
and how often
-check the water seal level every 2 hours, and add fluid as
