N618: Saunders Respiratory questions with correct
answers
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-Answers: 3,4,5,6
Rationale:
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
notification of the health care provider. 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 is assisting a health care provider with the removal of a chest
tube. The nurse should instruct the client to take which action?
1. Stay very still.
2. Exhale very quickly.
3. Inhale and exhale quickly.
4. Perform the Valsalva maneuver. Correct Answer-Answers: 4
Rationale:
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tube is quickly withdrawn, and an airtight dressing is taped in place.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.
The nurse caring for a client with a pneumothorax and who has had a
chest tube inserted notes continuous gentle bubbling in the water seal
chamber. What action is most appropriate?
1. Do nothing, because this is an expected finding.
2. Check for an air leak, because the bubbling should be intermittent.
,3. Increase the suction pressure so that the bubbling becomes vigorous.
4.Clamp the chest tube and notify the health care provider immediately.
Correct Answer-Answer: 2
Rationale:
Fluctuation with inspiration and expiration, not continuous bubbling,
should be noted in the water seal chamber. Intermittent bubbling may be
noted if the client has a known pneumothorax, but this should decrease
as time goes on and as the pneumothorax begins to resolve. Therefore,
the nurse should check for an air leak. If a wet chest drainage system is
used, bubbling would be continuous in the suction control chamber and
not intermittent. In a dry system, there is no bubbling. Increasing the
suction pressure only increases the rate of evaporation of water in the
drainage system; in addition, increasing the suction can be harmful and
is not done without a specific prescription to do so if using a wet system.
Dry systems will allow for only a certain amount of suction to be
applied; an orange bellow will appear in the suction window, indicating
that the proper amount of suction has been applied. Chest tubes should
be clamped only with a health care provider's prescription.
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 Correct Answer-Answer: 2
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. Hyperresonance also may occur
on the affected side. A sucking sound at the site of injury would be noted
with an open chest injury.
The nurse is caring for a client hospitalized with acute exacerbation of
chronic obstructive pulmonary disease. Which findings would the nurse
expect to note on assessment of this client?
Select all that apply.
1. A low arterial PCo2 level
2. A hyperinflated chest noted on the chest x-ray
3. Decreased oxygen saturation with mild exercise
4. A widened diaphragm noted on the chest x-ray
5.Pulmonary function tests that demonstrate increased vital capacity
Correct Answer-Answers: 2,3
Rationale:
Clinical manifestations of chronic obstructive pulmonary disease
(COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at
rest, oxygen desaturation with exercise, and the use of accessory
muscles of respiration. Chest x-rays reveal a hyperinflated chest and a
flattened diaphragm if the disease is advanced. Pulmonary function tests
will demonstrate decreased vital capacity.
answers
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-Answers: 3,4,5,6
Rationale:
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
notification of the health care provider. 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 is assisting a health care provider with the removal of a chest
tube. The nurse should instruct the client to take which action?
1. Stay very still.
2. Exhale very quickly.
3. Inhale and exhale quickly.
4. Perform the Valsalva maneuver. Correct Answer-Answers: 4
Rationale:
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.
The nurse caring for a client with a pneumothorax and who has had a
chest tube inserted notes continuous gentle bubbling in the water seal
chamber. What action is most appropriate?
1. Do nothing, because this is an expected finding.
2. Check for an air leak, because the bubbling should be intermittent.
,3. Increase the suction pressure so that the bubbling becomes vigorous.
4.Clamp the chest tube and notify the health care provider immediately.
Correct Answer-Answer: 2
Rationale:
Fluctuation with inspiration and expiration, not continuous bubbling,
should be noted in the water seal chamber. Intermittent bubbling may be
noted if the client has a known pneumothorax, but this should decrease
as time goes on and as the pneumothorax begins to resolve. Therefore,
the nurse should check for an air leak. If a wet chest drainage system is
used, bubbling would be continuous in the suction control chamber and
not intermittent. In a dry system, there is no bubbling. Increasing the
suction pressure only increases the rate of evaporation of water in the
drainage system; in addition, increasing the suction can be harmful and
is not done without a specific prescription to do so if using a wet system.
Dry systems will allow for only a certain amount of suction to be
applied; an orange bellow will appear in the suction window, indicating
that the proper amount of suction has been applied. Chest tubes should
be clamped only with a health care provider's prescription.
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 Correct Answer-Answer: 2
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. Hyperresonance also may occur
on the affected side. A sucking sound at the site of injury would be noted
with an open chest injury.
The nurse is caring for a client hospitalized with acute exacerbation of
chronic obstructive pulmonary disease. Which findings would the nurse
expect to note on assessment of this client?
Select all that apply.
1. A low arterial PCo2 level
2. A hyperinflated chest noted on the chest x-ray
3. Decreased oxygen saturation with mild exercise
4. A widened diaphragm noted on the chest x-ray
5.Pulmonary function tests that demonstrate increased vital capacity
Correct Answer-Answers: 2,3
Rationale:
Clinical manifestations of chronic obstructive pulmonary disease
(COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at
rest, oxygen desaturation with exercise, and the use of accessory
muscles of respiration. Chest x-rays reveal a hyperinflated chest and a
flattened diaphragm if the disease is advanced. Pulmonary function tests
will demonstrate decreased vital capacity.
