Practice Mode– Questions and choices are randomly arranged, the answer is revealed instantly after each question, and there is no time limit for the exam.
MSN Exam for Pneumothorax (PM)
Choose the letter of the correct answer. Good luck!
Start
Congratulations - you have completed MSN Exam for Pneumothorax (PM).
You scored %%SCORE%% out of %%TOTAL%%.
Your performance has been rated as %%RATING%%
Your answers are highlighted below.
Question 1
After a lateral crushing chest injury, obvious right-sided paradoxic motion of the client’s chest demonstrates multiple rib fraactures, resulting in a flail chest. The complication the nurse should carefully observe for would be:
A
Open pneumothorax
B
Tracheal laceration
C
Mediastinal shift
D
Pericardial tamponade
Question 1 Explanation:
Mediastinal structures move toward the uninjured lung, reducing oxygenation and venous return.
Question 2
In a recumbent, immobilized patient, lung ventilation can become altered, leading to such respiratory complications as:
A
Respiratory acidosis, ateclectasis, and hypostatic pneumonia
B
Cheyne-Strokes respirations and spontaneous pneumothorax
C
Kussmail’s respirations and hypoventilation
D
Appneustic breathing, atypical pneumonia and respiratory alkalosis
Question 2 Explanation:
Because of restricted respiratory movement, a recumbent, immobilize patient is at particular risk for respiratory acidosis from poor gas exchange; atelectasis from reduced surfactant and accumulated mucus in the bronchioles, and hypostatic pneumonia from bacterial growth caused by stasis of mucus secretions.
Question 3
A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the BEST explanation for the nurse to provide this client?
A
“The tube will seal the hole in your lung.”
B
“The tube controls the amount of air that enters your chest.”
C
“The tube will remove excess air from your chest.”
D
“The tube will drain fluid from your chest.”
Question 3 Explanation:
The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.
Question 4
The physician inserts a chest tube into a female client to treat a pneumothorax. The tube is connected to water-seal drainage. The nurse in-charge can prevent chest tube air leaks by:
A
Checking patency of the chest tube.
B
Keeping the head of the bed slightly elevated.
C
Checking and taping all connections.
D
Keeping the chest drainage system below the level of the chest.
Question 4 Explanation:
Air leaks commonly occur if the system isn’t secure. Checking all connections and taping them will prevent air leaks. The chest drainage system is kept lower to promote drainage – not to prevent leaks.
Question 5
Nurse Kim is caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is appropriate?
A
Immediately clamp the chest tube and notify the physician.
B
Increase the suction pressure so that bubbling becomes vigorous.
C
Do nothing, because this is an expected finding.
D
Check for an air leak because the bubbling should be intermittent.
Question 5 Explanation:
Continuous gentle bubbling should be noted in the suction control chamber. Immediately clamp the chest tube and notify the physician is incorrect. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy). Checking for an air leak because the bubbling should be intermittent is incorrect. Bubbling should be continuous and not intermittent. Increase the suction pressure so that bubbling becomes vigorous is incorrect because bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system.
Question 6
A male client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breathe sounds in right upper lobe of the lung. The nurse immediately assesses for other signs of:
A
Displaced endotracheal tube
B
Pulmonary embolism
C
Acute respiratory distress syndrome
D
Right pneumothorax
Question 6 Explanation:
Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left main stem bronchi.
Question 7
A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?
A
“The tube will drain fluid from your chest.”
B
“The tube will remove excess air from your chest.”
C
“The tube will seal the hole in your lung.”
D
“The tube controls the amount of air that enters your chest.”
Question 7 Explanation:
The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.
Question 8
The nurse is going to replace the Pleur-O-Vac attached to the client with a small, persistent left upper lobe pneumothorax with a Heimlich Flutter Valve. Which of the following is the best rationale for this?
A
Eliminate the need for a water-seal drainage
B
Prevent kinking of the tube
C
Eliminate the need for a dressing
D
Promote air and pleural drainage
Question 8 Explanation:
The Heimlich flutter valve has a one-way valve that allows air and fluid to drain. Underwater seal drainage is not necessary. This can be connected to a drainage bag for the patient’s mobility. The absence of a long drainage tubing and the presence of a one-way valve promote effective therapy
Question 9
An emergency room nurse is assessing a female client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client?
A
A sucking sound at the site of injury
B
The presence of a barrel chest
C
A low respiratory
D
Diminished breathe sounds
Question 9 Explanation:
This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.
Question 10
The nurse is planning to teach the client about a spontaneous pneumothorax. The nurse would base the teaching on the understanding that:
A
Inspired air will move from the lung into the pleural space.
B
The other lung will collapse if not treated immediately.
C
There is greater negative pressure within the chest cavity.
D
The heart and great vessels shift to the affected side.
Question 10 Explanation:
As a person with a tear in the lung inhales, air moves through that opening into the intrapleural and causes partial or complete collapse of the lungs.
Question 11
When planning discharge teaching for a young female client who has had a pneumothorax, it is important that the nurse include the signs and symptoms of a pneumothorax and teach the client to seek medical assistance if she experiences:
A
Episodes of palpitation
B
Severe shortness of breath
C
Substernal chest pain
D
Dizziness when standing up
Question 11 Explanation:
This could indicate a recurrence of the pneumothorax as one side of the lung is inadequate to meet the oxygen demands of the body.
Question 12
A thoracentesis is performed on a chest-injured client, and no fluid or air is found. Blood and fluids is administered intravenously (IV), but the client’s vital signs do not improve. A central venous pressure line is inserted, and the initial reading is 20 cm H^O. The most likely cause of these findings is which of the following?
A
Ruptured diaphragm
B
Pericardial tamponade
C
Hemothorax
D
Spontaneous pneumothorax
Question 12 Explanation:
Pericardial tamponade occurs when there is presence of fluid accumulation in the pericardial space that compresses on the ventricles causing a decrease in ventricular filling and stretching during diastole with a decrease in cardiac output. . This leads to right atrial and venous congestion manifested by a CVP reading above normal.
Question 13
Nurse Oliver observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?
A
The system is functioning normally
B
The system has an air leak.
C
The chest tube is obstructed
D
The client has a pneumothorax
Question 13 Explanation:
Constant bubbling in the chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.
Question 14
Which of the following measures best determines that a patient who had a pneumothorax no longer needs a chest tube?
A
The water-seal chamber doesn’t fluctuate when no suction is applied.
B
You see a lot of drainage from the chest tube.
C
Arterial blood gas (ABG) levels are normal.
D
The chest X-ray continues to show the lung is 35% deflated.
Question 14 Explanation:
The chest tube isn’t removed until the patient’s lung has adequately reexpanded and is expected to stay that way. One indication of reexpansion is the cessation of fluctuation in the water-seal chamber when suction isn’t applied. The chest X-ray should show that the lung is reexpanded. Drainage should be minimal before the chest tube is removed. An ABG test isn’t necessary if clinical assessment criteria are met.
Question 15
When caring for the a client with a pneumothorax, who has a chest tube in place, nurse Kate should plan to:
A
Empty and measure the drainage in the collection chamber each shift
B
Administer cough suppressants at appropriate intervals as ordered
C
Encourage coughing, deep breathing, and range of motion to the arm on the affected side
D
Apply clamps below the insertion site when ever getting the client out of bed
Question 15 Explanation:
All these interventions promote aeration of the re-expanding lung and maintenance of function in the arm and shoulder on the affected side.
Once you are finished, click the button below. Any items you have not completed will be marked incorrect.
Get Results
There are 15 questions to complete.
←
List
→
Return
Shaded items are complete.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
End
Return
You have completed
questions
question
Your score is
Correct
Wrong
Partial-Credit
You have not finished your quiz. If you leave this page, your progress will be lost.
Correct Answer
You Selected
Not Attempted
Final Score on Quiz
Attempted Questions Correct
Attempted Questions Wrong
Questions Not Attempted
Total Questions on Quiz
Question Details
Results
Date
Score
Hint
Time allowed
minutes
seconds
Time used
Answer Choice(s) Selected
Question Text
All done
Need more practice!
Keep trying!
Not bad!
Good work!
Perfect!
Exam Mode
Exam Mode – Questions and choices are randomly arranged, time limit of 1min per question, answers and grade will be revealed after finishing the exam.
MSN Exam for Pneumothorax (EM)
Choose the letter of the correct answer. You got 15 minutes to finish the exam .Good luck!
Start
Congratulations - you have completed MSN Exam for Pneumothorax (EM).
You scored %%SCORE%% out of %%TOTAL%%.
Your performance has been rated as %%RATING%%
Your answers are highlighted below.
Question 1
The physician inserts a chest tube into a female client to treat a pneumothorax. The tube is connected to water-seal drainage. The nurse in-charge can prevent chest tube air leaks by:
A
Checking and taping all connections.
B
Checking patency of the chest tube.
C
Keeping the chest drainage system below the level of the chest.
D
Keeping the head of the bed slightly elevated.
Question 1 Explanation:
Air leaks commonly occur if the system isn’t secure. Checking all connections and taping them will prevent air leaks. The chest drainage system is kept lower to promote drainage – not to prevent leaks.
Question 2
Which of the following measures best determines that a patient who had a pneumothorax no longer needs a chest tube?
A
The water-seal chamber doesn’t fluctuate when no suction is applied.
B
You see a lot of drainage from the chest tube.
C
Arterial blood gas (ABG) levels are normal.
D
The chest X-ray continues to show the lung is 35% deflated.
Question 2 Explanation:
The chest tube isn’t removed until the patient’s lung has adequately reexpanded and is expected to stay that way. One indication of reexpansion is the cessation of fluctuation in the water-seal chamber when suction isn’t applied. The chest X-ray should show that the lung is reexpanded. Drainage should be minimal before the chest tube is removed. An ABG test isn’t necessary if clinical assessment criteria are met.
Question 3
Nurse Oliver observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?
A
The system has an air leak.
B
The client has a pneumothorax
C
The chest tube is obstructed
D
The system is functioning normally
Question 3 Explanation:
Constant bubbling in the chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.
Question 4
The nurse is going to replace the Pleur-O-Vac attached to the client with a small, persistent left upper lobe pneumothorax with a Heimlich Flutter Valve. Which of the following is the best rationale for this?
A
Promote air and pleural drainage
B
Eliminate the need for a water-seal drainage
C
Prevent kinking of the tube
D
Eliminate the need for a dressing
Question 4 Explanation:
The Heimlich flutter valve has a one-way valve that allows air and fluid to drain. Underwater seal drainage is not necessary. This can be connected to a drainage bag for the patient’s mobility. The absence of a long drainage tubing and the presence of a one-way valve promote effective therapy
Question 5
In a recumbent, immobilized patient, lung ventilation can become altered, leading to such respiratory complications as:
A
Cheyne-Strokes respirations and spontaneous pneumothorax
B
Kussmail’s respirations and hypoventilation
C
Respiratory acidosis, ateclectasis, and hypostatic pneumonia
D
Appneustic breathing, atypical pneumonia and respiratory alkalosis
Question 5 Explanation:
Because of restricted respiratory movement, a recumbent, immobilize patient is at particular risk for respiratory acidosis from poor gas exchange; atelectasis from reduced surfactant and accumulated mucus in the bronchioles, and hypostatic pneumonia from bacterial growth caused by stasis of mucus secretions.
Question 6
When caring for the a client with a pneumothorax, who has a chest tube in place, nurse Kate should plan to:
A
Administer cough suppressants at appropriate intervals as ordered
B
Encourage coughing, deep breathing, and range of motion to the arm on the affected side
C
Apply clamps below the insertion site when ever getting the client out of bed
D
Empty and measure the drainage in the collection chamber each shift
Question 6 Explanation:
All these interventions promote aeration of the re-expanding lung and maintenance of function in the arm and shoulder on the affected side.
Question 7
A thoracentesis is performed on a chest-injured client, and no fluid or air is found. Blood and fluids is administered intravenously (IV), but the client’s vital signs do not improve. A central venous pressure line is inserted, and the initial reading is 20 cm H^O. The most likely cause of these findings is which of the following?
A
Spontaneous pneumothorax
B
Pericardial tamponade
C
Ruptured diaphragm
D
Hemothorax
Question 7 Explanation:
Pericardial tamponade occurs when there is presence of fluid accumulation in the pericardial space that compresses on the ventricles causing a decrease in ventricular filling and stretching during diastole with a decrease in cardiac output. . This leads to right atrial and venous congestion manifested by a CVP reading above normal.
Question 8
After a lateral crushing chest injury, obvious right-sided paradoxic motion of the client’s chest demonstrates multiple rib fraactures, resulting in a flail chest. The complication the nurse should carefully observe for would be:
A
Mediastinal shift
B
Open pneumothorax
C
Tracheal laceration
D
Pericardial tamponade
Question 8 Explanation:
Mediastinal structures move toward the uninjured lung, reducing oxygenation and venous return.
Question 9
A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?
A
“The tube controls the amount of air that enters your chest.”
B
“The tube will remove excess air from your chest.”
C
“The tube will drain fluid from your chest.”
D
“The tube will seal the hole in your lung.”
Question 9 Explanation:
The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.
Question 10
A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the BEST explanation for the nurse to provide this client?
A
“The tube will remove excess air from your chest.”
B
“The tube controls the amount of air that enters your chest.”
C
“The tube will drain fluid from your chest.”
D
“The tube will seal the hole in your lung.”
Question 10 Explanation:
The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.
Question 11
Nurse Kim is caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is appropriate?
A
Check for an air leak because the bubbling should be intermittent.
B
Increase the suction pressure so that bubbling becomes vigorous.
C
Do nothing, because this is an expected finding.
D
Immediately clamp the chest tube and notify the physician.
Question 11 Explanation:
Continuous gentle bubbling should be noted in the suction control chamber. Immediately clamp the chest tube and notify the physician is incorrect. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy). Checking for an air leak because the bubbling should be intermittent is incorrect. Bubbling should be continuous and not intermittent. Increase the suction pressure so that bubbling becomes vigorous is incorrect because bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system.
Question 12
The nurse is planning to teach the client about a spontaneous pneumothorax. The nurse would base the teaching on the understanding that:
A
There is greater negative pressure within the chest cavity.
B
The heart and great vessels shift to the affected side.
C
Inspired air will move from the lung into the pleural space.
D
The other lung will collapse if not treated immediately.
Question 12 Explanation:
As a person with a tear in the lung inhales, air moves through that opening into the intrapleural and causes partial or complete collapse of the lungs.
Question 13
When planning discharge teaching for a young female client who has had a pneumothorax, it is important that the nurse include the signs and symptoms of a pneumothorax and teach the client to seek medical assistance if she experiences:
A
Severe shortness of breath
B
Substernal chest pain
C
Episodes of palpitation
D
Dizziness when standing up
Question 13 Explanation:
This could indicate a recurrence of the pneumothorax as one side of the lung is inadequate to meet the oxygen demands of the body.
Question 14
An emergency room nurse is assessing a female client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client?
A
A sucking sound at the site of injury
B
A low respiratory
C
Diminished breathe sounds
D
The presence of a barrel chest
Question 14 Explanation:
This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.
Question 15
A male client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breathe sounds in right upper lobe of the lung. The nurse immediately assesses for other signs of:
A
Right pneumothorax
B
Acute respiratory distress syndrome
C
Pulmonary embolism
D
Displaced endotracheal tube
Question 15 Explanation:
Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left main stem bronchi.
Once you are finished, click the button below. Any items you have not completed will be marked incorrect.
Get Results
There are 15 questions to complete.
←
List
→
Return
Shaded items are complete.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
End
Return
You have completed
questions
question
Your score is
Correct
Wrong
Partial-Credit
You have not finished your quiz. If you leave this page, your progress will be lost.
Correct Answer
You Selected
Not Attempted
Final Score on Quiz
Attempted Questions Correct
Attempted Questions Wrong
Questions Not Attempted
Total Questions on Quiz
Question Details
Results
Date
Score
Hint
Time allowed
minutes
seconds
Time used
Answer Choice(s) Selected
Question Text
All done
Need more practice!
Keep trying!
Not bad!
Good work!
Perfect!
Text Mode
Text Mode – Text version of the exam
1) Nurse Kim is caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is appropriate?
Do nothing, because this is an expected finding.
Immediately clamp the chest tube and notify the physician.
Check for an air leak because the bubbling should be intermittent.
Increase the suction pressure so that bubbling becomes vigorous.
2) An emergency room nurse is assessing a female client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client?
A low respiratory
Diminished breathe sounds
The presence of a barrel chest
A sucking sound at the site of injury
3) A male client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breathe sounds in right upper lobe of the lung. The nurse immediately assesses for other signs of:
Right pneumothorax
Pulmonary embolism
Displaced endotracheal tube
Acute respiratory distress syndrome
4) The physician inserts a chest tube into a female client to treat a pneumothorax. The tube is connected to water-seal drainage. The nurse in-charge can prevent chest tube air leaks by:
Checking and taping all connections.
Checking patency of the chest tube.
Keeping the head of the bed slightly elevated.
Keeping the chest drainage system below the level of the chest.
5) A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?
“The tube will drain fluid from your chest.”
“The tube will remove excess air from your chest.”
“The tube controls the amount of air that enters your chest.”
“The tube will seal the hole in your lung.”
6) A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the BEST explanation for the nurse to provide this client?
“The tube will drain fluid from your chest.”
“The tube will remove excess air from your chest.”
“The tube controls the amount of air that enters your chest.”
“The tube will seal the hole in your lung.”
7) Which of the following measures best determines that a patient who had a pneumothorax no longer needs a chest tube?
You see a lot of drainage from the chest tube.
Arterial blood gas (ABG) levels are normal.
The chest X-ray continues to show the lung is 35% deflated.
The water-seal chamber doesn’t fluctuate when no suction is applied.
8) The nurse is going to replace the Pleur-O-Vac attached to the client with a small, persistent left upper lobe pneumothorax with a Heimlich Flutter Valve. Which of the following is the best rationale for this?
Promote air and pleural drainage
Prevent kinking of the tube
Eliminate the need for a dressing
Eliminate the need for a water-seal drainage
9) A thoracentesis is performed on a chest-injured client, and no fluid or air is found. Blood and fluids is administered intravenously (IV), but the client’s vital signs do not improve. A central venous pressure line is inserted, and the initial reading is 20 cm H^O. The most likely cause of these findings is which of the following?
Spontaneous pneumothorax
Ruptured diaphragm
Hemothorax
Pericardial tamponade
10) The nurse is planning to teach the client about a spontaneous pneumothorax. The nurse would base the teaching on the understanding that:
Inspired air will move from the lung into the pleural space.
There is greater negative pressure within the chest cavity.
The heart and great vessels shift to the affected side.
The other lung will collapse if not treated immediately.
11) Nurse Oliver observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?
The system is functioning normally
The client has a pneumothorax
The system has an air leak.
The chest tube is obstructed
12) In a recumbent, immobilized patient, lung ventilation can become altered, leading to such respiratory complications as:
Respiratory acidosis, ateclectasis, and hypostatic pneumonia
Appneustic breathing, atypical pneumonia and respiratory alkalosis
Cheyne-Strokes respirations and spontaneous pneumothorax
Kussmail’s respirations and hypoventilation
13) After a lateral crushing chest injury, obvious right-sided paradoxic motion of the client’s chest demonstrates multiple rib fraactures, resulting in a flail chest. The complication the nurse should carefully observe for would be:
Mediastinal shift
Tracheal laceration
Open pneumothorax
Pericardial tamponade
14) When planning discharge teaching for a young female client who has had a pneumothorax, it is important that the nurse include the signs and symptoms of a pneumothorax and teach the client to seek medical assistance if she experiences:
Substernal chest pain
Episodes of palpitation
Severe shortness of breath
Dizziness when standing up
15) When caring for the a client with a pneumothorax, who has a chest tube in place, nurse Kate should plan to:
Administer cough suppressants at appropriate intervals as ordered
Empty and measure the drainage in the collection chamber each shift
Apply clamps below the insertion site when ever getting the client out of bed
Encourage coughing, deep breathing, and range of motion to the arm on the affected side
Answers and Rationales
A. Do nothing, because this is an expected finding. Continuous gentle bubbling should be noted in the suction control chamber. Immediately clamp the chest tube and notify the physician is incorrect. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy). Checking for an air leak because the bubbling should be intermittent is incorrect. Bubbling should be continuous and not intermittent. Increase the suction pressure so that bubbling becomes vigorous is incorrect because bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system.
B. Diminished breathe sounds. This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.
A. Right pneumothorax . Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left main stem bronchi.
A. Checking and taping all connections. Air leaks commonly occur if the system isn’t secure. Checking all connections and taping them will prevent air leaks. The chest drainage system is kept lower to promote drainage – not to prevent leaks.
B. “The tube will remove excess air from your chest.” The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.
B. “The tube will remove excess air from your chest.” The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.
D. The water-seal chamber doesn’t fluctuate when no suction is applied. The chest tube isn’t removed until the patient’s lung has adequately reexpanded and is expected to stay that way. One indication of reexpansion is the cessation of fluctuation in the water-seal chamber when suction isn’t applied. The chest X-ray should show that the lung is reexpanded. Drainage should be minimal before the chest tube is removed. An ABG test isn’t necessary if clinical assessment criteria are met.
D. Eliminate the need for a water-seal drainage . The Heimlich flutter valve has a one-way valve that allows air and fluid to drain. Underwater seal drainage is not necessary. This can be connected to a drainage bag for the patient’s mobility. The absence of a long drainage tubing and the presence of a one-way valve promote effective therapy
D. Pericardial tamponade . Pericardial tamponade occurs when there is presence of fluid accumulation in the pericardial space that compresses on the ventricles causing a decrease in ventricular filling and stretching during diastole with a decrease in cardiac output. . This leads to right atrial and venous congestion manifested by a CVP reading above normal.
B. There is greater negative pressure within the chest cavity. As a person with a tear in the lung inhales, air moves through that opening into the intrapleural and causes partial or complete collapse of the lungs.
C. The system has an air leak. Constant bubbling in the chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.
A. Respiratory acidosis, ateclectasis, and hypostatic pneumonia . Because of restricted respiratory movement, a recumbent, immobilize patient is at particular risk for respiratory acidosis from poor gas exchange; atelectasis from reduced surfactant and accumulated mucus in the bronchioles, and hypostatic pneumonia from bacterial growth caused by stasis of mucus secretions.
A. Mediastinal shift . Mediastinal structures move toward the uninjured lung, reducing oxygenation and venous return.
C. Severe shortness of breath . This could indicate a recurrence of the pneumothorax as one side of the lung is inadequate to meet the oxygen demands of the body.
D. Encourage coughing, deep breathing, and range of motion to the arm on the affected side . All these interventions promote aeration of the re-expanding lung and maintenance of function in the arm and shoulder on the affected side.