Saunders NCLEX Questions
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1. The nurse caring for a client with a chest 2.
tube turns the client to the side and the Place the tube in a bottle of sterile water.
chest tube accidentally disconnects from
the water seal chamber. Which initial nurs- If the chest drainage system is disconnect-
ing action should the nurse take? ed, the end of the tube is placed in a bottle
of sterile water held below the level of the
1. chest. The HCP may need to be notified,
Call the health care provider (HCP). but this is not the initial action. The system
is replaced if it breaks or cracks or if the
2. collection chamber is full. Placing a ster-
Place the tube in a bottle of sterile water. ile dressing over the disconnection site will
not prevent complications resulting from the
3.
disconnection.
Replace the chest tube system.
4.
Place a sterile dressing over the discon-
nection site.
2. The nurse is assessing the functioning of 3.
a chest tube drainage system in a client Drainage system maintained below the
who has just returned from the recovery client's chest
room following a thoracotomy with wedge
resection. Which are the expected assess- 4.
ment findings? Select all that apply. 50 mL of drainage in the drainage collection
chamber
1.
Excessive bubbling in the water seal cham- 5.
ber Occlusive dressing in place over the chest
tube insertion site
2.
Vigorous bubbling in the suction control 6.
chamber Fluctuation of water in the tube in the water
, Saunders NCLEX Questions
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seal chamber during inhalation and exhala-
3. tion
Drainage system maintained below the
client's chest The bubbling of water in the water seal
chamber indicates air drainage from the
4. client and usually is seen when intratho-
50 mL of drainage in the drainage collec- racic pressure is higher than atmospheric
tion chamber pressure, and may occur during exhalation,
coughing, or sneezing. Excessive bubbling
5.
in the water seal chamber may indicate an
Occlusive dressing in place over the chest
air leak, an unexpected finding. Fluctuation
tube insertion site
of water in the tube in the water seal cham-
ber during inhalation and exhalation is ex-
6.
pected. An absence of fluctuation may indi-
Fluctuation of water in the tube in the
cate that the chest tube is obstructed or that
water seal chamber during inhalation and
the lung has reexpanded and that no more
exhalation
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 re-
covery 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.
3. The nurse is assisting a health care 4.
provider with the removal of a chest tube. Perform the Valsalva maneuver.
, Saunders NCLEX Questions
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The nurse should instruct the client to take
which action? When the chest tube is removed, the client
is asked to perform the Valsalva maneu-
1. ver (take a deep breath, exhale, and bear
Exhale slowly. down). The tube is quickly withdrawn, and
an airtight dressing is taped in place. An
2. alternative instruction is to ask the client to
Stay very still. take a deep breath and hold the breath
while the tube is removed.
3.
Inhale and exhale quickly.
4.
Perform the Valsalva maneuver.
4. While changing the tapes on a tracheosto- 2.
my tube, the client coughs and the tube Grasp the retention sutures to spread the
is dislodged. Which is the initial nursing opening.
action?
If the tube is dislodged accidentally, the ini-
1. tial nursing action is to grasp the retention
Call the health care provider to reinsert sutures and spread the opening. If agency
the tube. policy permits, the nurse then attempts im-
mediately to replace the tube. Calling ancil-
2. lary services or the HCP will delay treatment
Grasp the retention sutures to spread the in this emergency situation. Covering the
opening. tracheostomy site will block the airway.
3.
Call the respiratory therapy department to
reinsert the tracheotomy.
4.
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Cover the tracheostomy site with a sterile
dressing to prevent infection.
5. The nurse is caring for a client immediate- 1.
ly after removal of the endotracheal tube. Stridor
The nurse should report which sign imme-
diately if experienced by the client? Following removal of the endotracheal tube
the nurse monitors the client for respira-
1. tory distress. The nurse reports stridor to
Stridor the health care provider (HCP) immediately.
This is a high-pitched, coarse sound that
2. is heard with the stethoscope over the tra-
Occasional pink-tinged sputum chea. Stridor indicates airway edema and
places the client at risk for airway obstruc-
3.
tion. Although the findings identified in the
Respiratory rate of 24 breaths/minute
remaining options require monitoring, they
do not require immediate notification of the
4.
health care provider.
A few basilar lung crackles on the right
6. The nurse caring for a client with a pneu- 1
mothorax and who has had a chest tube
inserted notes continuous gentle bub- Continuous gentle bubbling should be not-
bling in the suction control chamber. What ed in the suction control chamber. Bubbling
action is most appropriate? should be continuous in the suction con-
trol chamber and not intermittent. Increas-
1. ing the suction pressure only increases the
Do nothing, because this is an expected rate of evaporation of water in the drainage
finding. system; in addition, increasing the suction
can be harmful and is not done without a
2. specific prescription to do so. Chest tubes
Check for an air leak because the bubbling should only be clamped to check for an
should be intermittent.
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1. The nurse caring for a client with a chest 2.
tube turns the client to the side and the Place the tube in a bottle of sterile water.
chest tube accidentally disconnects from
the water seal chamber. Which initial nurs- If the chest drainage system is disconnect-
ing action should the nurse take? ed, the end of the tube is placed in a bottle
of sterile water held below the level of the
1. chest. The HCP may need to be notified,
Call the health care provider (HCP). but this is not the initial action. The system
is replaced if it breaks or cracks or if the
2. collection chamber is full. Placing a ster-
Place the tube in a bottle of sterile water. ile dressing over the disconnection site will
not prevent complications resulting from the
3.
disconnection.
Replace the chest tube system.
4.
Place a sterile dressing over the discon-
nection site.
2. The nurse is assessing the functioning of 3.
a chest tube drainage system in a client Drainage system maintained below the
who has just returned from the recovery client's chest
room following a thoracotomy with wedge
resection. Which are the expected assess- 4.
ment findings? Select all that apply. 50 mL of drainage in the drainage collection
chamber
1.
Excessive bubbling in the water seal cham- 5.
ber Occlusive dressing in place over the chest
tube insertion site
2.
Vigorous bubbling in the suction control 6.
chamber Fluctuation of water in the tube in the water
, Saunders NCLEX Questions
Study online at https://quizlet.com/_a4zkdr
seal chamber during inhalation and exhala-
3. tion
Drainage system maintained below the
client's chest The bubbling of water in the water seal
chamber indicates air drainage from the
4. client and usually is seen when intratho-
50 mL of drainage in the drainage collec- racic pressure is higher than atmospheric
tion chamber pressure, and may occur during exhalation,
coughing, or sneezing. Excessive bubbling
5.
in the water seal chamber may indicate an
Occlusive dressing in place over the chest
air leak, an unexpected finding. Fluctuation
tube insertion site
of water in the tube in the water seal cham-
ber during inhalation and exhalation is ex-
6.
pected. An absence of fluctuation may indi-
Fluctuation of water in the tube in the
cate that the chest tube is obstructed or that
water seal chamber during inhalation and
the lung has reexpanded and that no more
exhalation
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 re-
covery 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.
3. The nurse is assisting a health care 4.
provider with the removal of a chest tube. Perform the Valsalva maneuver.
, Saunders NCLEX Questions
Study online at https://quizlet.com/_a4zkdr
The nurse should instruct the client to take
which action? When the chest tube is removed, the client
is asked to perform the Valsalva maneu-
1. ver (take a deep breath, exhale, and bear
Exhale slowly. down). The tube is quickly withdrawn, and
an airtight dressing is taped in place. An
2. alternative instruction is to ask the client to
Stay very still. take a deep breath and hold the breath
while the tube is removed.
3.
Inhale and exhale quickly.
4.
Perform the Valsalva maneuver.
4. While changing the tapes on a tracheosto- 2.
my tube, the client coughs and the tube Grasp the retention sutures to spread the
is dislodged. Which is the initial nursing opening.
action?
If the tube is dislodged accidentally, the ini-
1. tial nursing action is to grasp the retention
Call the health care provider to reinsert sutures and spread the opening. If agency
the tube. policy permits, the nurse then attempts im-
mediately to replace the tube. Calling ancil-
2. lary services or the HCP will delay treatment
Grasp the retention sutures to spread the in this emergency situation. Covering the
opening. tracheostomy site will block the airway.
3.
Call the respiratory therapy department to
reinsert the tracheotomy.
4.
, Saunders NCLEX Questions
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Cover the tracheostomy site with a sterile
dressing to prevent infection.
5. The nurse is caring for a client immediate- 1.
ly after removal of the endotracheal tube. Stridor
The nurse should report which sign imme-
diately if experienced by the client? Following removal of the endotracheal tube
the nurse monitors the client for respira-
1. tory distress. The nurse reports stridor to
Stridor the health care provider (HCP) immediately.
This is a high-pitched, coarse sound that
2. is heard with the stethoscope over the tra-
Occasional pink-tinged sputum chea. Stridor indicates airway edema and
places the client at risk for airway obstruc-
3.
tion. Although the findings identified in the
Respiratory rate of 24 breaths/minute
remaining options require monitoring, they
do not require immediate notification of the
4.
health care provider.
A few basilar lung crackles on the right
6. The nurse caring for a client with a pneu- 1
mothorax and who has had a chest tube
inserted notes continuous gentle bub- Continuous gentle bubbling should be not-
bling in the suction control chamber. What ed in the suction control chamber. Bubbling
action is most appropriate? should be continuous in the suction con-
trol chamber and not intermittent. Increas-
1. ing the suction pressure only increases the
Do nothing, because this is an expected rate of evaporation of water in the drainage
finding. system; in addition, increasing the suction
can be harmful and is not done without a
2. specific prescription to do so. Chest tubes
Check for an air leak because the bubbling should only be clamped to check for an
should be intermittent.
