SAUNDERS NCLEX EXAM PREP |ACTUAL
QUESTIONS AND VERIFIED ANSWERS|BRAND NEW
2026-2027 UPDATE|GRADED A+
Question 1
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?
1.
Call the health care provider (HCP).
2.
Place the tube in a bottle of sterile water.
3.
Replace the chest tube system.
4.
Place a sterile dressing over the disconnection site.
CORRECT ANSWER
2.
Place the tube in a bottle of sterile water.
If the chest drainage system is disconnected, the end of the tube is placed in a bottle of
sterile water held below the level of the chest. The HCP may need to be notified, but this is
not the initial action. The system is replaced if it breaks or cracks or if the collection chamber
is full. Placing a sterile dressing over the disconnection site will not prevent complications
resulting from the disconnection.
1
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,Question 2
The nurse is assessing the functioning of a chest tube drainage system in a client who has
just returned from the recovery room following a thoracotomy with wedge resection.
Which are the expected assessment findings? Select all that apply.
1.
Excessive bubbling in the water seal chamber
2.
Vigorous bubbling in the suction control chamber
3.
Drainage system maintained below the client's chest
4.
50 mL of drainage in the drainage collection chamber
5.
Occlusive dressing in place over the chest tube insertion site
6.
Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation
CORRECT ANSWER
3.
Drainage system maintained below the client's chest
2
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,4.
50 mL of drainage in the drainage collection chamber
5.
Occlusive dressing in place over the chest tube insertion site
6.
Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation
The bubbling of water in the water seal chamber indicates air drainage from the client and
usually is seen when intrathoracic pressure is higher than atmospheric pressure, and may
occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal
chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in
the water seal chamber during inhalation and exhalation is expected. An absence of
fluctuation may indicate that the chest tube is obstructed or that the lung has reexpanded
and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should
be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a
client returning to the nursing unit from the recovery room. Drainage that is more than 70 to
100 mL/hour is considered excessive and requires health care provider notification. The
chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from
entering the pleural space. Positioning the drainage system below the client's chest allows
gravity to drain the pleural space.
Question 3
The nurse is assisting a health care provider with the removal of a chest tube. The nurse
should instruct the client to take which action?
1.
Exhale slowly.
2.
3
@https://www.stuvia.com/user/thestudyvault
, Stay very still.
3.
Inhale and exhale quickly.
4.
Perform the Valsalva maneuver.
CORRECT ANSWER
4.
Perform the Valsalva maneuver.
When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take
a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an airtight
dressing is taped in place. An alternative instruction is to ask the client to take a deep breath
and hold the breath while the tube is removed.
Question 4
While changing the tapes on a tracheostomy tube, the client coughs and the tube is
dislodged. Which is the initial nursing action?
1.
Call the health care provider to reinsert the tube.
2.
Grasp the retention sutures to spread the opening.
3.
Call the respiratory therapy department to reinsert the tracheotomy.
4
@https://www.stuvia.com/user/thestudyvault
QUESTIONS AND VERIFIED ANSWERS|BRAND NEW
2026-2027 UPDATE|GRADED A+
Question 1
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?
1.
Call the health care provider (HCP).
2.
Place the tube in a bottle of sterile water.
3.
Replace the chest tube system.
4.
Place a sterile dressing over the disconnection site.
CORRECT ANSWER
2.
Place the tube in a bottle of sterile water.
If the chest drainage system is disconnected, the end of the tube is placed in a bottle of
sterile water held below the level of the chest. The HCP may need to be notified, but this is
not the initial action. The system is replaced if it breaks or cracks or if the collection chamber
is full. Placing a sterile dressing over the disconnection site will not prevent complications
resulting from the disconnection.
1
@https://www.stuvia.com/user/thestudyvault
,Question 2
The nurse is assessing the functioning of a chest tube drainage system in a client who has
just returned from the recovery room following a thoracotomy with wedge resection.
Which are the expected assessment findings? Select all that apply.
1.
Excessive bubbling in the water seal chamber
2.
Vigorous bubbling in the suction control chamber
3.
Drainage system maintained below the client's chest
4.
50 mL of drainage in the drainage collection chamber
5.
Occlusive dressing in place over the chest tube insertion site
6.
Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation
CORRECT ANSWER
3.
Drainage system maintained below the client's chest
2
@https://www.stuvia.com/user/thestudyvault
,4.
50 mL of drainage in the drainage collection chamber
5.
Occlusive dressing in place over the chest tube insertion site
6.
Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation
The bubbling of water in the water seal chamber indicates air drainage from the client and
usually is seen when intrathoracic pressure is higher than atmospheric pressure, and may
occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal
chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in
the water seal chamber during inhalation and exhalation is expected. An absence of
fluctuation may indicate that the chest tube is obstructed or that the lung has reexpanded
and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should
be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a
client returning to the nursing unit from the recovery room. Drainage that is more than 70 to
100 mL/hour is considered excessive and requires health care provider notification. The
chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from
entering the pleural space. Positioning the drainage system below the client's chest allows
gravity to drain the pleural space.
Question 3
The nurse is assisting a health care provider with the removal of a chest tube. The nurse
should instruct the client to take which action?
1.
Exhale slowly.
2.
3
@https://www.stuvia.com/user/thestudyvault
, Stay very still.
3.
Inhale and exhale quickly.
4.
Perform the Valsalva maneuver.
CORRECT ANSWER
4.
Perform the Valsalva maneuver.
When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take
a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an airtight
dressing is taped in place. An alternative instruction is to ask the client to take a deep breath
and hold the breath while the tube is removed.
Question 4
While changing the tapes on a tracheostomy tube, the client coughs and the tube is
dislodged. Which is the initial nursing action?
1.
Call the health care provider to reinsert the tube.
2.
Grasp the retention sutures to spread the opening.
3.
Call the respiratory therapy department to reinsert the tracheotomy.
4
@https://www.stuvia.com/user/thestudyvault
