NUR 210 (M1) - Chest Tubes & Pneumothorax
Exam Questions With Verified Answers
The emergency department nurse is assessing a client who has sustained a
blunt injury to the chest wall. Which finding indicates the presence of a
pneumothorax in this client?
1. A low respiratory rate
2. Diminished breath sounds
3. The presence of a barrel chest
4. A sucking sound at the site of injury - ANSWER 2. Diminished breath sounds
Rationale:
This client has sustained a blunt or 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. Hyper-resonance also may occur on the affected
side. A sucking sound at the site of injury would be noted with an open chest
injury.
The client is admitted to the emergency department with chest trauma. Which
signs/ symptoms indicate to the nurse the diagnosis of pneumothorax?
1. Bronchovesicular lung sounds and bradypnea.
2. Unequal lung expansion and dyspnea.
3. Frothy, bloody sputum and consolidation.
4. Barrel chest and polycythemia. - ANSWER 2. Unequal lung expansion and
dyspnea.
The client had a right-sided chest tube inserted two (2) hours ago for a
pneumothorax. Which action should the nurse implement if there is no
fluctuation (tidaling) in the water-seal compartment?
1. Obtain an order for a STAT chest x-ray.
2. Increase the amount of wall suction.
3. Check the tubing for kinks or clots.
4. Monitor the client's pulse oximeter reading. - ANSWER 3. Check the tubing for
kinks or clots.
Rationale:
1. A STAT chest x-ray would not be needed to determine why there is no
fluctuation in the water-seal compartment.
2. Increasing the amount of wall suction does not address why there is no
fluctuation in the water-seal compartment.
, 3. The key to the answer is "2 hours." The air from the pleural space is not able
to get to the water-seal compartment, and the nurse should try to determine
why. Usually the client is lying on the tube, it is kinked, or there is a dependent
loop.
4. The stem does not state the client is in respiratory distress, and a pulse
oximeter reading detects hypoxemia but does not address any fluctuation in the
water-seal compartment.
Which intervention should the nurse implement for a male client who has had a
left-sided chest tube for six (6) hours and who refuses to take deep breaths
because of the pain?
1. Medicate the client and have the client take deep breaths.
2. Encourage the client to take shallow breaths to help with the pain.
3. Explain deep breaths do not have to be taken at this time.
4. Tell the client if he doesn't take deep breaths, he could die. - ANSWER 1.
Medicate the client and have the client take deep breaths
Rationale
1. The client must take deep breaths to help push the air out of the pleural space
into the water-seal drainage, and deep breaths will help prevent the client from
developing pneumonia or atelectasis.
2. The client must take deep breaths; shallow breaths could lead to
complications.
3. Deep breaths must be taken to prevent complications.
4. This is a cruel intervention; the nurse can medicate the client and then
encourage deep breathing.
If the test taker reads options "2" and "3" and notices that both reflect the same
idea—namely, that deep breaths are not necessary—then both can either be
eliminated as incorrect answers or kept as possible correct answers. Option "4"
should be eliminated based on being a very rude and threatening comment.
The unlicensed assistive personnel (UAP) assists the client with a chest tube to
ambulate to the bathroom. Which situation warrants immediate intervention
from the nurse?
1. The UAP keeps the chest tube below chest level.
2. The UAP has the chest tube attached to suction.
3. The UAP allowed the client out of the bed.
4. The UAP uses a bedside commode for the
client. - ANSWER 2. The UAP has the chest tube attached to suction.
Rationale:
1. Keeping the drainage system lower than the chest promotes drainage and
prevents reflux.
2. The chest tube system can function as a result of gravity and does not have to
be attached to suction. Keeping it attached to suction could cause the client to
Exam Questions With Verified Answers
The emergency department nurse is assessing a client who has sustained a
blunt injury to the chest wall. Which finding indicates the presence of a
pneumothorax in this client?
1. A low respiratory rate
2. Diminished breath sounds
3. The presence of a barrel chest
4. A sucking sound at the site of injury - ANSWER 2. Diminished breath sounds
Rationale:
This client has sustained a blunt or 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. Hyper-resonance also may occur on the affected
side. A sucking sound at the site of injury would be noted with an open chest
injury.
The client is admitted to the emergency department with chest trauma. Which
signs/ symptoms indicate to the nurse the diagnosis of pneumothorax?
1. Bronchovesicular lung sounds and bradypnea.
2. Unequal lung expansion and dyspnea.
3. Frothy, bloody sputum and consolidation.
4. Barrel chest and polycythemia. - ANSWER 2. Unequal lung expansion and
dyspnea.
The client had a right-sided chest tube inserted two (2) hours ago for a
pneumothorax. Which action should the nurse implement if there is no
fluctuation (tidaling) in the water-seal compartment?
1. Obtain an order for a STAT chest x-ray.
2. Increase the amount of wall suction.
3. Check the tubing for kinks or clots.
4. Monitor the client's pulse oximeter reading. - ANSWER 3. Check the tubing for
kinks or clots.
Rationale:
1. A STAT chest x-ray would not be needed to determine why there is no
fluctuation in the water-seal compartment.
2. Increasing the amount of wall suction does not address why there is no
fluctuation in the water-seal compartment.
, 3. The key to the answer is "2 hours." The air from the pleural space is not able
to get to the water-seal compartment, and the nurse should try to determine
why. Usually the client is lying on the tube, it is kinked, or there is a dependent
loop.
4. The stem does not state the client is in respiratory distress, and a pulse
oximeter reading detects hypoxemia but does not address any fluctuation in the
water-seal compartment.
Which intervention should the nurse implement for a male client who has had a
left-sided chest tube for six (6) hours and who refuses to take deep breaths
because of the pain?
1. Medicate the client and have the client take deep breaths.
2. Encourage the client to take shallow breaths to help with the pain.
3. Explain deep breaths do not have to be taken at this time.
4. Tell the client if he doesn't take deep breaths, he could die. - ANSWER 1.
Medicate the client and have the client take deep breaths
Rationale
1. The client must take deep breaths to help push the air out of the pleural space
into the water-seal drainage, and deep breaths will help prevent the client from
developing pneumonia or atelectasis.
2. The client must take deep breaths; shallow breaths could lead to
complications.
3. Deep breaths must be taken to prevent complications.
4. This is a cruel intervention; the nurse can medicate the client and then
encourage deep breathing.
If the test taker reads options "2" and "3" and notices that both reflect the same
idea—namely, that deep breaths are not necessary—then both can either be
eliminated as incorrect answers or kept as possible correct answers. Option "4"
should be eliminated based on being a very rude and threatening comment.
The unlicensed assistive personnel (UAP) assists the client with a chest tube to
ambulate to the bathroom. Which situation warrants immediate intervention
from the nurse?
1. The UAP keeps the chest tube below chest level.
2. The UAP has the chest tube attached to suction.
3. The UAP allowed the client out of the bed.
4. The UAP uses a bedside commode for the
client. - ANSWER 2. The UAP has the chest tube attached to suction.
Rationale:
1. Keeping the drainage system lower than the chest promotes drainage and
prevents reflux.
2. The chest tube system can function as a result of gravity and does not have to
be attached to suction. Keeping it attached to suction could cause the client to
