QUESTIONS AND CORRECT ANSWERS VERSIONS CURRENTLY
TESTING COMPLETE QUESTIONS WITH DETAILED VERIFIED
ANSWERS WITH RATIONALES /ALREADY GRADED A+
A client with unresolved hemothorax is febrile, with chills and
sweating. He has a nonproductive cough and chest pain. His
chest tube drainage is turbid. What should the nurse request
in SBAR communication with the health care provider?
Portable chest X-ray
Antibiotic therapy
Intubation and mechanical ventilation
Arterial blood gasses - ANSWER-Antibiotic therapy
Any condition that produces fluid accumulation or
sequestration of fluid with infective properties can lead to
empyema, an accumulation of pus in a body cavity, especially
the pleural space, as a result of bacterial infection. An infected
chest tube site, lobar pneumonia, and P. carinii pneumonia can
,lead to fever, chills, and sweating associated with infection.
With the symptoms of infection, antibiotic therapy would be
recommended. Nothing in the question demonstrates a need
for chest X-ray, intubation, or ABGs.
A client has a chest tube inserted for the treatment of a
pneumothorax. While turning in the bed, the client dislodges
the tube and it is found in the bed. As the registered nurse is
directing the health care team, place the actions of the
registered nurse in the correct order. All options must be
used. - ANSWER-Apply an occlusive dressing over the puncture
site
Tape the dressing on three sides
Direct the licensed practical/vocational nurse (LPN/VN) to
notify the health care provider.
Assess the client's respiratory status.
Assess vital signs and await further medical orders
A chest tube is a flexible, hollow tube placed through the chest
wall and in to the pleural space. The chest tube is able to
relieve trapped air and fluid. If a chest tube is dislodged and
comes out, the nurse would immediately apply an occlusive
dressing such as Vaseline gauze (many times kept in the client's
room). The dressing is taped on three sides. The first action
,always focuses on the client. The nurse would direct another
licensed nurse to immediately notify the health care provider.
The nurse would then assess the respiratory status. The nurse
would obtain vital signs and await further orders.
After having a lobectomy for lung cancer, a client receives a
chest tube connected to a three-chamber chest drainage
system. The nurse observes that the drainage system is
functioning correctly when noting which of the following?
Select all that apply.
Fluctuations in the water-seal chamber occur when the client
breathes.
Crepitus forms at the chest tube insertion site.
Intermittent bubbling occurs in the water-seal chamber.
Gentle bubbling occurs in the suction control chamber.
Drainage is collecting in the drainage chamber. - ANSWER-
Fluctuations in the water-seal chamber occur when the client
breathes.
Intermittent bubbling occurs in the water-seal chamber.
Gentle bubbling occurs in the suction control chamber.
Drainage is collecting in the drainage chamber.
, Fluctuations in the water-seal compartment (or tidal
movements) indicate normal function of the system as the
pressure in the tubing changes with the client's respirations.
There also should be intermittent bubbling in the water-seal
chamber, indicating that air is being removed from the pleural
cavity by the system. Gentle bubbling in the suction control
chamber indicates that the proper suction level has been
reached. Drainage is expected to collect in the drainage
chamber after a lobectomy. Crepitus indicates that air is leaking
into the subcutaneous tissues. The physician should be notified
of this finding.
The nurse is planning care for a child with a pneumothorax.
The nurse adds the nursing diagnosis, "Risk for injury related
to potential dislodgement of chest tube" to the care plan.
When writing the care plan, what should the nurse be sure to
include as interventions?
Keep dry gauze at the bedside
Ensure a pair of hemostats are at the bedside
Monitor pulse oximetry readings
Assess lungs as directed by the physician or as the client's
condition warrants