Chest Tube And Drainage Device Care - NCLEX Pn
- Identify the correct routine site care for a chest tube insertion dressing.
- Maintain sterile occlusive dressing; change per policy using sterile technique. Prevents infection and maintains airtight seal at the insertion site per evidence-based protocols.
- What is the appropriate immediate nursing action when continuous bubbling is observed in the water-seal chamber?
- Check connections and tubing for leaks; notify RN/provider if unresolved. Identifies and resolves potential system leaks to prevent complications like tension pneumothorax.
- Which option is the correct statement about stripping or milking chest tube tubing?
- Do not strip routinely; only if specifically ordered per policy. Avoids high negative pressure surges that may damage lung tissue unless clinically indicated.
- What does the absence of tidaling in the water-seal chamber most commonly suggest?
- Lung re-expansion or tubing obstruction (kink/clot). Indicates resolution of pneumothorax or potential blockage impeding pressure transmission.
- What is the correct finding that suggests subcutaneous emphysema near the insertion site?
- Crepitus (crackling) on palpation. Indicates air trapped under skin from leakage, detectable by palpation around the site.
- Which option is the correct documentation related to chest tube output?
- Record amount, color, and characteristics at ordered intervals. Tracks trends in pleural output to detect complications like hemorrhage or infection early.
- Identify the correct patient instruction to promote drainage and prevent complications.
- Perform deep breathing, coughing, and incentive spirometry as tolerated. Enhances lung expansion and drainage while reducing atelectasis and pneumonia risks.
- What does continuous bubbling in the water-seal chamber most strongly indicate?
- Air leak in the system. Suggests ongoing air entry exceeding normal tidaling, often from loose connections or pleural fistula.
- What is the correct way to manage chest tube clamps at the bedside?
- Keep clamps available; do not clamp routinely unless ordered. Prepares for emergencies like disconnection while avoiding routine use that risks tension pneumothorax.
- What is the correct expected finding in the suction-control chamber when suction is applied?
- Gentle, continuous bubbling (wet suction) or indicator confirms suction (dry). Confirms effective application of prescribed suction to facilitate pleural evacuation.
- What is the primary purpose of a chest tube connected to a drainage device?
- Remove air or fluid to re-expand lung and restore negative pressure. Restores intrapleural negative pressure essential for lung function by evacuating accumulated air or fluid from the pleural space.
- Which option best describes the function of the water-seal chamber in a chest drain?
- One-way valve that prevents air from re-entering the pleural space. Maintains negative pressure by allowing air and fluid to exit while blocking atmospheric air re-entry.
- Identify the expected finding in the water-seal chamber with normal respiration.
- Tidaling (rise with inspiration, fall with expiration). Reflects normal intrapleural pressure changes during the respiratory cycle in a patent system.
- Which option is the correct action if the suction is ordered but there is no bubbling/indicator?
- Verify wall suction, regulator setting, and tubing connections. Ensures proper suction delivery by troubleshooting equipment and setup issues systematically.
- Which option is the correct position for a chest drainage system relative to the chest?
- Below the level of the chest at all times. Prevents backflow of drainage into the chest by maintaining gravitational flow and negative pressure gradient.
- Which option best explains why an occlusive dressing is taped on three sides after dislodgement?
- Creates a flutter valve to prevent tension pneumothorax. Facilitates air escape during exhalation but prevents influx, reducing tension pneumothorax risk.
- Identify the correct action when transporting a patient with a chest drainage system.
- Keep system below chest, upright, and avoid dependent loops in tubing. Ensures continuous drainage and system integrity during movement to prevent complications.
- What is the correct action if the drainage system tips over and the chambers mix?
- Set upright, assess patient, and notify RN/provider; replace if needed. Restores system integrity and assesses for complications while ensuring prompt intervention to maintain functionality.
- What is the correct action if the chest tube becomes disconnected from the drainage tubing?
- Place tube end in sterile water and notify RN/provider immediately. Restores water seal temporarily to prevent atmospheric air entry while seeking immediate help.
- What is the correct action if drainage suddenly increases markedly or becomes bright red?
- Assess patient and notify RN/provider immediately. Indicates possible hemorrhage or complication requiring immediate evaluation and intervention.
- Which option is the priority action if new or worsening subcutaneous emphysema is noted?
- Assess respiratory status and notify RN/provider promptly. Addresses potential air leak progression that could compromise respiratory function urgently.
- What is the correct action if the chest tube is accidentally pulled out of the patient?
- Apply sterile occlusive dressing taped on three sides; notify immediately. Seals the site to prevent air entry while allowing emergency intervention for complications.
- Identify the priority assessment immediately after chest tube insertion.
- Respiratory status and breath sounds. Evaluates lung re-expansion and detects complications like pneumothorax or bleeding early.
- What is the correct method to maintain tube patency during routine care?
- Keep tubing straight and free of dependent loops and kinks. Promotes continuous drainage and prevents occlusions that could lead to tension pneumothorax.