- What is the best response by the nurse?
Answer: "These exercises help your lung to expand and push the air and fluid out."
The correct answer is B. This response provides a clear and simple rationale for why coughing and deep breathing are necessary, connecting the action to the goal of care (lung re-expansion). A is dismissive and non-therapeutic. C is true (it helps prevent pneumonia) but can be fear-inducing; B focuses on the positive goal. D is also important and should be offered, but it doesn't answer the client's question about why the exercises are needed.
- What is the nurse's immediate action?
Answer: Place the end of the chest tube in a bottle of sterile water.
The correct answer is A. If the chest tube disconnects from the drainage system, the immediate action is to place the end of the tube in a bottle of sterile water or saline. This creates a temporary water seal, which prevents air from entering the pleural space while a new drainage system is prepared. B: Clamping the tube is dangerous and can lead to a tension pneumothorax. C: Reconnecting a contaminated tube introduces pathogens into the pleural space. D: Covering with sterile gauze does not create the necessary water seal to prevent air entry.
- Which finding should the nurse report to the RN?
Answer: Cessation of drainage and client's report of dyspnea.
The correct answer is A. The sudden cessation of drainage, especially when coupled with respiratory distress, is a significant finding that may indicate a blockage or clot in the tubing. This prevents air or fluid from escaping the pleural space, potentially leading to a tension pneumothorax. This is the most critical finding and must be reported immediately. B, C, and D represent expected or less urgent findings.
- Which piece of information is missing from this documentation?
Answer: The amount of suction applied to the system.
The correct answer is B. Complete chest tube documentation must include the suction level being applied to the drainage system, as this is essential information for evaluating proper system function and ensuring continuity of care. The suction setting is a critical component that affects drainage effectiveness and must be documented with each assessment. While vital signs are important, they may be documented separately in the vital signs record.
- Which action should the nurse take?
Answer: Record the 25 mL of output on the intake and output record.
The correct answer is C. A total of 25 mL of serosanguineous drainage over 3 hours (about 8 mL/hour) is a small and expected amount of drainage. The appropriate action is to document this normal finding. A: This amount does not suggest hemorrhage. B: Milking or stripping tubes is not routinely recommended as it can create dangerously high negative pressure. D: There is no indication for a STAT chest x-ray based on this finding.
- Which fluid should the nurse obtain to fill the water seal chamber?
Answer: Sterile water.
The correct answer is B. The water seal chamber of a chest drainage unit should be filled with sterile water to prevent introducing microorganisms into the system and to ensure proper function. While some facilities may use tap water, sterile water is the preferred standard. Hydrogen peroxide and povidone-iodine are antiseptics and are not appropriate for this purpose.
- Which intervention is most important to include for promoting lung re-expansion?
Answer: Encouraging the client to use the incentive spirometer every hour while awake.
The correct answer is B. Using an incentive spirometer, along with deep breathing and coughing exercises, helps to increase lung volume, prevent atelectasis, and promote the re-expansion of the affected lung. This is a critical component of care for any client with a chest tube. A: Ambulation and position changes are encouraged to promote drainage and lung expansion. C: Frequent position changes are needed. D: Fluid restriction is not indicated unless there is a co-existing condition like heart failure.
- What is the immediate nursing action?
Answer: Apply a sterile occlusive dressing taped on three sides.
The correct answer is C. If a chest tube is accidentally removed, the immediate priority is to prevent air from entering the pleural space. The nurse should cover the site with a sterile occlusive dressing (such as petroleum gauze) and tape it on three sides. This creates a flutter valve effect, allowing air to escape from the pleural space on exhalation but preventing air from entering on inhalation. A is outside the LPN scope and can cause injury. B is not an adequate seal. D is an important assessment, but it should be done after the site is covered to prevent further complications.
- In addition to applying the restraints, which action is a priority for the nurse to ensure client safety?
Answer: Secure the drainage tubing to the client's gown and bed linen.
The correct answer is B. Securing the tubing to the gown (allowing slack for movement) and then to the bed linen helps prevent the client from accidentally dislodging the tube if they pull on it. This simple intervention adds a layer of safety. A: Clamps are kept at the bedside for emergencies like system changes or disconnection, but clamping a tube in a confused client who might have an air leak is dangerous. C: Administering a sedative may be necessary, but it is not a direct safety measure for the tube itself and requires an order. D: While helpful, relying on family is not a guaranteed nursing safety intervention.
- Which action should the LPN take?
Answer: Mark the area with a skin marker and notify the RN.
The correct answer is B. The crackling sensation is subcutaneous emphysema (crepitus), which occurs when air leaks from the pleural space into the subcutaneous tissues. The LPN should mark the outer border of the affected area to monitor for any increase in size and immediately notify the RN. This finding can indicate a worsening air leak or a malpositioned tube. A and C do not address the underlying problem. D is incorrect; this is an abnormal finding that requires monitoring and reporting.
- Which observation indicates the system is functioning correctly?
Answer: The water level in the suction control chamber is at the 20 cm mark.
The correct answer is B. In a wet suction system, the amount of suction is determined by the height of the water column in the suction control chamber, not by the setting on the wall regulator. The provider ordered -20 cm H2O, so the water level should be at the 20 cm mark. Gentle, not vigorous (A), bubbling in this chamber indicates that suction is active. C is incorrect; the water seal chamber is filled only to the indicated line. D is incorrect because the wall suction should be set high enough to produce gentle bubbling, but the wall setting itself does not determine the pressure applied to the client's chest.
- Which type of dressing is most appropriate to have available for this procedure?
Answer: An occlusive petroleum gauze dressing.
The correct answer is C. The dressing around a chest tube insertion site must be occlusive (airtight) to prevent air from entering the pleural space through the opening. A petroleum gauze dressing is a common type of occlusive dressing used for this purpose. It is typically covered with sterile gauze and secured with tape. A, B, and D are not occlusive and would not be appropriate for a chest tube site.
- Which action should the LPN take immediately?
Answer: Call for immediate assistance and notify the RN.
The correct answer is B. These are classic signs and symptoms of a tension pneumothorax, a life-threatening medical emergency. The LPN's immediate priority is to recognize this critical situation and call for help, which includes activating the rapid response team (if available) and notifying the RN. While a quick system check (C) is good, it should not delay calling for help in a deteriorating client. A and D are incorrect and could worsen the client's condition.
- What should be the nurse's first action?
Answer: Check the tubing for any kinks or obstructions.
The correct answer is A. The cessation of tidaling (fluctuation) combined with respiratory distress suggests an obstruction in the chest tube system. The first action is to quickly assess for and correct any common, reversible causes, such as kinks in the tubing or the client lying on the tube. This simple intervention may resolve the issue immediately. After checking the tubing, the nurse should notify the RN of the findings and the client's respiratory distress. B may be appropriate but does not address the potential cause. C should be done after the quick assessment. D is beyond the LPN's scope and premature.
- Which action should the nurse take first?
Answer: Check the client's vital signs.
The correct answer is B. Drainage of more than 100-150 mL/hour of bright red blood, especially after the initial post-operative period, can indicate active bleeding or hemorrhage. The first action is to collect further data, specifically vital signs, to assess for signs of hemodynamic instability (e.g., hypotension, tachycardia). After gathering this critical data, the nurse must immediately report all findings to the RN as this is an abnormal finding requiring immediate attention. A: Simply documenting is unsafe as this finding is abnormal and requires immediate reporting. C: Repositioning does not address the potential for hemorrhage. D: Administering pain medication is not the priority when hemorrhage is suspected.
- Which instruction should the nurse reinforce with the client?
Answer: Ensure the drainage unit is kept below the level of your chest.
The correct answer is C. The chest drainage unit must always be kept below the level of the client's chest to prevent backflow of fluid into the pleural space and to allow for gravity drainage. A: Keeping the unit at chest level would prevent proper drainage. B: Clamping the chest tube is contraindicated during ambulation as it can cause a tension pneumothorax if an air leak is present. D: The system should never be disconnected.
- Which instruction should the LPN anticipate reinforcing with the client just before the tube is removed?
Answer: "Take a deep breath and hold it."
The correct answer is A. The client is instructed to take a deep breath, hold it, and bear down (Valsalva maneuver) during chest tube removal. This action increases intrathoracic pressure and prevents air from being sucked into the pleural space as the tube is withdrawn. B, C, and D are incorrect instructions that could increase the risk of air entry into the pleural space.
- How should the nurse confirm that the correct amount of suction is being applied?
Answer: Check that the dial on the drainage device is set to 20.
The correct answer is C. In a dry suction system, the amount of suction is controlled by a regulator dial on the device itself. The nurse confirms the correct suction level by ensuring this dial is set to the prescribed level, which is -20 cm H2O in this case. A: Bubbling in the water seal chamber indicates an air leak, not the level of suction. B: The wall suction must be turned on, but the setting on the wall unit does not regulate the pressure applied to the client; the device itself does. An orange float or other indicator will confirm suction is active.
- Which finding in the water seal chamber should the nurse recognize as an expected finding for this client?
Answer: Fluctuation of the water level with respirations.
The correct answer is B. Fluctuation of the water level with respirations, known as tidaling, is an expected finding that indicates the chest tube is patent and functioning properly. A: Continuous bubbling indicates an air leak in the system or from the client. C: Absence of tidaling may indicate that the lung has re-expanded (a desired outcome) or that there is a kink or obstruction in the tubing. D: A high water level is not a specific expected finding and does not indicate proper function.
- What is the priority nursing action?
Answer: Lift and drain the tubing content into the collection chamber.
The correct answer is B. Dependent loops can collect fluid and obstruct the flow of drainage from the pleural space, which can impede lung re-expansion. The priority action is to lift the tubing to allow the fluid to drain into the collection chamber, ensuring the system remains patent. A: Notifying the RN is not the priority; this is a situation the LPN can and should correct. C: Increasing suction will not resolve the obstruction caused by the fluid-filled loop. D: Documentation is necessary, but correcting the problem is the immediate priority.
