SAUNDERS NCLEX QUESTIONS &
DETAILED COMPLETE SOLUTIONS
RATED 100% CORRECT
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
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.
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.
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.
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.
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.
Cover the tracheostomy site with a sterile dressing to prevent infection. - correct answer ✔✔2.
Grasp the retention sutures to spread the opening.
If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures
and spread the opening. If agency policy permits, the nurse then attempts immediately to
DETAILED COMPLETE SOLUTIONS
RATED 100% CORRECT
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
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.
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.
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.
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.
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.
Cover the tracheostomy site with a sterile dressing to prevent infection. - correct answer ✔✔2.
Grasp the retention sutures to spread the opening.
If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures
and spread the opening. If agency policy permits, the nurse then attempts immediately to
