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Ch. 19 Intraoperative Nursing Care

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Gravity

The physical environment of a surgery suite is designed primarily to promote

a. electrical safety
b. medical and surgical asepsis
c. comfort and privacy of the patient
d. communication among the surgical team
B- Medical and surgical asepsis
Although all the factors are important to the safety and well being of the patient, the first
consideration in the physical environment of the surgical suite is prevention of transmission of
infection to the patient
When transporting an inpatient to the surgical department, the nurse from another area of the
hospital has access to
a. the clean core
b. the holding area
c. corridors of the surgical suite
d. an unprepared operating room
 B- The holding area
Persons in street clothes or attire other than surgical scrub clothing can interact
with personnel of the surgical suite in unrestricted areas, such as the holding
area, nursing station, control desk, or lockers rooms. Only authorized personnel
wearing surgical attire and hair covering are allowed in semirestricted areas,
such as corridors, and masks must be worn in restricted areas, such as operating
rooms, clean core, and scrub sink areas.
1/27

Created by
agrablin5
Tags related to this set
Nursing

Terms in this set (27)

The physical environment of a surgery suite is designed primarily to promote

a. electrical safety
b. medical and surgical asepsis
c. comfort and privacy of the patient
d. communication among the surgical team
B- Medical and surgical asepsis
Although all the factors are important to the safety and well being of the patient, the first
consideration in the physical environment of the surgical suite is prevention of
transmission of infection to the patient
When transporting an inpatient to the surgical department, the nurse from another area
of the hospital has access to
a. the clean core
b. the holding area
c. corridors of the surgical suite
d. an unprepared operating room
B- The holding area
Persons in street clothes or attire other than surgical scrub clothing can interact with
personnel of the surgical suite in unrestricted areas, such as the holding area, nursing
station, control desk, or lockers rooms. Only authorized personnel wearing surgical
attire and hair covering are allowed in semirestricted areas, such as corridors, and
masks must be worn in restricted areas, such as operating rooms, clean core, and
scrub sink areas.
Identify five examples of data collected during the perioperative nurse's physical
assessment of the patient that indicate special considerations of the patient's needs
during surgery:
1) allergy to skin preparation agents, adhesive tapes, or latex
2) musculoskeletal impairments requiring adaptations in positioning
3) pain requiring adaptation in moving or procedures
4) decreased level of consciousness requiring increased safety and protection
techniques
5) Vision and hearing impairments requiring adaptations in communication
6) piercings that require removal of jewelry before elctrosurgery
Also: skin conditions requiring special skin preparation and precautions against infection
The primary goal of the circulating nurse during preparation of the operating room,
transferring and positioning the patient, and assisting the anesthesia team is
a. avoiding any type of injury to the patient
b. maintaining a clean environment for the patient
c. providing for patient comfort and sense of well being
d. preventing breaks in aseptic technique by the sterile members of the team
C- Providing for patient comfort and sense of well being
The protection of the patient from injury in the operating room environment is
maintained by the circulating nurse by ensuring functioning equipment, preventing falls
and injury during transport and transfer, monitoring asepsis, and being with the patient
during anesthesia induction
Goals for patient safety in the operating room (OR) include the Universal Protocol, in
which
a. all surgical centers of any type must submit reports on patient safety infractions to the
accreditation agencies
b. the members of the surgical team stop whatever they are doing to check that all
sterile items have been properly prepared
c. a surgical timeout is performed just before the procedure is started to verify patient
identity, surgical procedure, and surgical site
d. all members of the surgical team pause right before surgery to meditate for 1 minute
to decrease stress and possible errors
C- The Universal Protocol supported by The Joint Commission is used to prevent wrong
site, wrong procedure, and wrong surgery in view of a high rate of these problems
nationally. It involves pausing just before the procedure starts to verify identity, site, and
procedure.
A break in sterile technique during surgery would occur when the scrub nurse touches
a. the mask with gloved hands
b. gloves hands to the gown at chest level
c. the drape at the incision site with gloved hands
d. the lower arms to the instruments on the instrument tray
A- The mask covering the face is not considered sterile, and if in contact with sterile
gloved hands, contaminates the gloves. The gown at chest level and to 2 inches above
elbows is considered sterile, as is the drape placed at the surgical area.
During surgery, a patient has a nursing diagnosis of risk for perioperative positioning
injury. A common risk factor for this nursing diagnosis is
a. skin lesions
b. break in sterile technique
c. musculoskeletal deformities
d. electrical or mechanical equipment failure
C- Musculoskeletal deformities can be a risk factor for positioning injuries and require
special padding and support on the operating table. Skin lesions and break in sterile
technique are risk factors for infection, and electrical equipment failure may lead to
other types of injuries.
At the end of the surgical procedure, the perioperative nurse evaluates the patient's
response to the nursing care delivered during the perioperative period. Which of the
following criteria reflects an outcome related to the patient's physical status?
a. the patient's right to privacy is maintained
b. the patient's care is consistent with the perioperative plan of care
c. the patient receives consistent and comparable care regardless of the setting
d. the patient's respiratory function is consistent with or improved from baseline levels
established preoperatively.
D- The Perioperative Nursing Data Set includes outcome statements that reflect
standards and recommended practices or perioperative nursing. Outcomes related to
physiologic responses include those of physiologic function, such as respiratory
function; perioperative safety includes the patient's freedom from any type of injury; and
behavioral responses include knowledge and actions of the patient and family, including
the consistency of the patient's care with the perioperative plan and the patient's right to
privacy.
The two short acting barbiturates most commonly used for induction of general
anesthesia are:
thiopental sodium (Pentothal) and sodium methohexital (Brevital)
Because of the rapid elimination of volatile liquids used for general anesthesia, the
nurse should anticipate that early in the anesthesia recovery period, the patient will
need
a. warm blankets
b. analgesic medication
c. observation for respiratory depression
d. airway protection in anticipation of vomiting
B- The volatile liquid inhalation agents have very little residual analgesia, and patients
experience early onset of pain when the agents are discontinued. They are associated
with a low incidence of nausea and vomiting. Prolonged respiratory depression is not
common because of their rapid elimination. Hypothermia is not related to use of these
agents, but they may precipitate malignant hyperthermia in conjunction with
neuromuscular blocking agents.
The primary advantage of the use of midazolam (Versed) as an adjunct to general
anesthesia is its
a. amnestic effect
b. analgesic effect
c. antiemetic effect
d. prolonged action
A- Amnestic effect
Midazolam (Versed) is a rapid, short acting, sedative-hypnotic benzodiazepine that is
used to prevent recall of events under anesthesia because of its amnestic properties.
Identify the rationale for the use of the following drugs during surgery and one nursing
implication indicated in the care of the patient immediately postoperatively related to the
drug
a. desflurane (Suprane)
Used for maintenance anesthesia- monitor for cardiopulmonary depression, early pain,
and nausea and vomiting
Identify the rationale for the use of the following drugs during surgery and one nursing
implication indicated in the care of the patient immediately postoperatively related to the
drug
b. ketamine (Ketalar)
Used for dissociative anesthesia with analgesia and amnesia- monitor for agitation,
hallucinations, nightmares
Identify the rationale for the use of the following drugs during surgery and one nursing
implication indicated in the care of the patient immediately postoperatively related to the
drug
c. Fentanyl (Sublimaze)
Induction and maintenance of anesthesia; promote early analgesia- assess for nausea
and vomiting, monitor respiratory status
Identify the rationale for the use of the following drugs during surgery and one nursing
implication indicated in the care of the patient immediately postoperatively related to the
drug
d. succinylcholine (Anectine)
Produce deep muscle relaxation- monitor respiratory muscle movement, airway
patency, and temperature
Monitored anesthesia care (MAC) is being considered for a patient undergoing a
cervical dilation and endometrial biopsy in health care provider's office. The patient asks
the nurse, "What is the MAC?" The nurse's response is based on the knowledge that
MAC
a. can be administered only by anesthesiologists or nurse anesthetists
b. enables the patient to respond to commands and accept painful procedures
c. should never be used outside of the OR because of the risk of serious complications
d. is so safe that it can be administered by nurses with direction from health care
providers
B- MAC refers to sedation that allows the patient to manage his or her own airway and
respond to commands, and yet the patient can emotionally and physically accept painful
procedures. Drugs are used to provide analgesia, relieve anxiety, and/or provide
amnesia. It can be administered by personnel other than anesthesiologists, but nurses
should be specially trained in the techniques of MAC to carry out this procedure
because of the high risk of complications resulting in clinical emergencies
Local infiltration
Injection of anesthetic agent directly into tissues
Epidural block
Injection of anesthetic agent into space around the vertebrae
Nerve block
Injection of a specific nerve with an anesthetic agent
Spinal block
Injection of agent into subarachnoid space
IV nerve block
Injection of agent into veins of extremity after limb is exsanguinated
During epidural and spinal anesthesia, the nurse should monitor the patient for
a. spinal headache
b. hypotension and bradycardia
c. loss of consciousness
d. downward extension of nerve block
B. During epidural and spinal anesthesia, a sympathetic nervous system blockade may
occur that results in hypotension, bradycardia, and nausea and vomiting. A spinal
headache may occur after, not during, spinal anesthesia, and unconsciousness and
seizures are indicative of IV absorption overdose. Upward extension of the effect of the
anesthesia results in inadequate respiratory excursion and apnea
A preoperative patient reveals that an uncle died during surgery because of a fever and
cardiac arrest. The perioperative nurse alerts the surgical team, knowing that if the
patient is at risk for malignant hyperthermia,
a. the surgery will have to be cancelled
b. specific precautions can be taken to safely anesthetize the patient
c. dantrolene (Dantrium) must be given to prevent hyperthermia during surgery
d. the patient should be placed on a cooling blanket during the surgical procedure
B- Although malignant hyperthermia can result in cardiac arrest and death, if the patient
is known or suspected to be at risk for the disorder, appropriate precautions taken by
the ACP can provide for safe anesthesia for the patient. Because preventive measures
are possible if the risk is known, it is critical that the preoperative assessment include a
careful family history of surgical events
General Anesthesia
Anticipated Patient Effects:
Loss of sensation with loss of consciousness; combination of hypnosis, analgesia, and
amnesia; skeletal muscle relaxation; possible impaired ventilatory and cardiovascular
function; elimination of coughing, gagging, vomiting, and sympathetic nervous system
responsiveness
Regional Anesthesia
Loss of sensation to a region of body without loss of consciousness; involves blocking a
specific nerve or group of nerves with administration of a local anesthetic; includes
spinal, caudal, and epidural anesthesia and IV and peripheral nerve blocks
Local Anesthesia
Loss of sensation without loss of consciousness; induced topically or via infiltration,
intracutaneously, or subcutaneously; topical applications may be aerosolized or
nebulized
Monitored Anesthesia Care (MAC)
similar to general anesthesia, sedatives and opioids are used but at a lower dosage;
does not involve inhalation agents; relieves anxiety, provides analgesia and amnesia;
patients remain responsive and breathe without assistance; may be used in conjunction
with regional or local anesthesia; often used for minor surgical procedures and
diagnostic procedures

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NCLEX: Perioperative Nursing

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Gravity

A patient is now in the recovery room after having vaginal surgery. Due to the
positioning of the procedure, you would want to assess for what while the patient
is in recovery?

A) Hemoglobin Level
B) Homan's Sign
C) Bowel Sounds
D) Dysrhythmia
D) Dysrhythmia

Vaginal surgeries require the patient to be in the lithotomy position. This position can put the patient
at risk for a deep vein thrombosis. Therefore, the nurse would want to check for this by using
Homan's Sign.
After surgery your patient is semicomatose with vital signs within
normal limits. As the nurse, what position would be best for this
patient?

A) Side positioning preferably on the left side

B) Prone
C) Semi-Fowlers
D) Low-Fowlers
A) Side positioning preferably on the left side

A patient who is semicomatose is at risk for aspiration (due to

secretions pooling in the mouth or vomiting which is a common side
effect of sedation). Placing the patient onto their side preferably the
left will help decrease the risk of aspiration and help promote
cardiovascular circulation.
1/15
Created by
Jan_Clark
Tags related to this set
Nursing
Foundations Of Professional Nursing
Incentive Spirometry
Urinary Tract Infections
Deep Vein Thrombosis

Terms in this set (15)

A patient is now in the recovery room after having vaginal surgery. Due to the
positioning of the procedure, you would want to assess for what while the patient is in
recovery?

A) Hemoglobin Level
B) Homan's Sign
C) Bowel Sounds
D) Dysrhythmia
D) Dysrhythmia

Vaginal surgeries require the patient to be in the lithotomy position. This position can
put the patient at risk for a deep vein thrombosis. Therefore, the nurse would want to
check for this by using Homan's Sign.
After surgery your patient is semicomatose with vital signs within normal limits. As the
nurse, what position would be best for this patient?

A) Side positioning preferably on the left side

B) Prone
C) Semi-Fowlers
D) Low-Fowlers
A) Side positioning preferably on the left side

A patient who is semicomatose is at risk for aspiration (due to secretions pooling in the
mouth or vomiting which is a common side effect of sedation). Placing the patient onto
their side preferably the left will help decrease the risk of aspiration and help promote
cardiovascular circulation.
After surgery your patient starts to shiver uncontrollably. What nursing intervention
would you do FIRST?

A) Apply warm blankets & continue oxygen as prescribed

B) Take the patient's rectal temperature
C) Page the doctor for further orders
D) Adjust the thermostat in the room
A) Apply warm blankets & continue oxygen as prescribed

Shivering is an early sign that the patient is starting to experience hypothermia.

Immediately, the nurse would need to control the shivering by applying warm blankets
and continue oxygen. When the patient starts to experience hypothermia, vital organs
are not receiving as much oxygenated blood due to the vasoconstriction. Therefore,
oxygen would need to be continued. Then the nurse would take the patient's
temperature.
The nurse is monitoring the patient who is 24 hours post-opt from surgery. Which
finding requires intervention?

A) 24 hour urine output of 300 mL

B) Pain rating of 4 on 1-10 scale
C) Temperature of 99.3' F
D) BP 100/80
A) 24 hour urine output of 300 mL

The nurse needs to watch the patient's urinary output closely. Urinary output within a 24
hour period should be at least 30 ml/hr. In this case, the patient is only urinating 12.5
ml/hr.
A patient is 6 days post-opt from abdominal surgery. The patient is to be discharged
later today. The patient uses the call light and asks you to come to his room and look at
his surgical site. On arrival, you see that approximately 2 inches of internal organs are
protruding through the incision. What intervention would you NOT do?

A) Cover the wound with sterile normal saline dressing

B) Put the patient in prone position with knees extended to
put pressure on the site
C) Monitor for signs of shock
D) Notify the MD and administer as prescribed antiemetic
to prevent vomiting
B) Put the patient in prone position with knees extended to
put pressure on the site

The patient is experiencing wound evisceration. This is an emergent situation. The

patient should be placed in low Fowler's position with the knees bent to prevent
abdominal tension.
A patient reports he hasn't had a bowel movement or passed gas since surgery. On
assessment, you note the abdomen is distended and no bowel sounds are noted in the
four quadrants. You notify the MD. What non-invasive nursing interventions can you
perform without a MD order?

A) Encourage at least 3000 ml of fluids per day

B) Encourage ambulation, maintain NPO status, and
monitor intake and output
C) Insert a nasogastric attached to intermittent suction
D) Administer IV fluids
A) Encourage ambulation, maintain NPO status, and
monitor intake and output

This patient is most likely experiencing a paralytic ileus which is failure for the bowels to
move its contents. The only correct non-invasive option is to encourage ambulation,
maintain NPO status, and monitor intake & output. Inserting a NG tube or administering
IV fluids is invasive and requires a MD order. Patients with potential paralytic ileus are
to be NPO (nothing by mouth) so encouraging fluid intake is incorrect.
What is a potential postoperative concern regarding a patient who has already resumed
a solid diet?

A) Failure to pass stool within 12 hours of eating solid foods

B) Failure to pass stool within 48 hours of eating solid
foods
C) Passage of excessive flatus
D) Patient reports a decreased appetite
B) Failure to pass stool within 48 hours of eating solid
foods

After a patient resumes solid food, they should have a bowel movement within 48 hours.
The patient may be experiencing constipation and appropriate interventions must be
followed.
A nurse is developing a care plan for a patient who is at risk for developing pneumonia
after surgery. Which of the following is not an appropriate nursing intervention?

A) Re-positioning every 3-4 hours

B) Encourage patient to use the incentive spirometer
device every 1-2 hours while awake
C) Encourage patient intake of 3000 ml/day of fluids if not
contraindicated
D) Encourage early ambulation and patient to eat meals in
bedside chair
A) Re-positioning every 3-4 hours

All options are correct expect for re-positioning every 3-4 hours. If the patient is unable
to re-position themselves or ambulate, they must be re-positioned every 1 to 2 hours
minimally.
When assessing your patient who is post-opt, you notice that the patient's right calf vein
feels hard, cord-like, and is tender to the touch. The patient reports it is aching and
painful. What would be an inappropriate nursing intervention for this patient?

A) Administer anticoagulants as ordered by MD

B) Instruct the patient to not sit in one position for a long
period of time
C) Allow the patient to dangle the legs to help increase
circulation and alleviate pain
D) Elevate the extremity 30 degrees without allowing any
pressure on affected area
C) Allow the patient to dangle the legs to help increase
circulation and alleviate pain

All options are correct expect for Allow the patient to dangle the legs to help increase
circulation and alleviate pain. The patient should NOT dangle the legs because this
causes blood to pool in the lower extremities which will put the patient at risk for another
blood clot formation.
A patient is recovering from surgery. The patient is very restless, heart rate is 120 bpm
and blood pressure is 70/53, skin is cool/clammy. As the nurse you would?

A) Notify the MD
B) Continue to monitor the patient
C) Check the patient's blood glucose
D) Obtain an EKG
A) Notify the MD

This is an emergency situation. The patient is more than likely experiencing a

hemorrhage of some type. Notifying the MD would be the first line of action and then
you could check the patient's blood glucose and obtain an EKG. This patient is probably
going to need a surgical intervention.
A patient is taking Aspirin 325 mg PO by mouth daily. The patient is scheduled for
surgery in a week. What education do you provide the patient with before surgery?

A) To hold his morning dose of Aspirin because the nurse

will give it to him before surgery
B) The medication should be discontinued for 48 hours
prior to the scheduled surgery date
C) None of the above are correct
D) Educate the patient to take the scheduled dose of
Aspirin the day of surgery to help prevent blood clots
B) The medication should be discontinued for 48 hours
prior to the scheduled surgery date

Aspirin alters the normal clotting factors and increases the patient's chances of
hemorrhaging. Therefore, it should be held for at least 48 hours prior to surgery as
specified by the surgeon.
You are observing your patient use the incentive spirometry. What demonstration by the
patient lets you know the patient understands how to use the device properly?

A) The patient inhales slowly on the device and maintains

the flow indicator between 600 to 900 level
B) The patient blows on the mouthpiece rapidly.
C) The patient rapidly inhales on the devices and exhales
D) The patient uses the incentive spirometry once a day
A) The patient inhales slowly on the device and maintains
the flow indicator between 600 to 900 level

All of the options are wrong expect for "The patient inhales slowly on the device and
maintains the flow indicator between 600 to 900 level". The other options do not
demonstrate how to properly use the incentive spirometry.
As the nurse you are getting the patient ready for surgery. You are completing the
preoperative checklist. Which of the following is not part of the preoperative checklist?

A) Assess for allergies

B) Conducting the Time Out
C) Informed consent is signed
D) Ensuring that the history and physical examination has
been completed
B) Conducting the Time Out

The time out is conducted by the OR nurse prior to surgery. All of the other options are
conducted by the nurse getting the patient ready for surgery.
You are completing the history on a patient who is scheduled to have surgery. What
health history increases the risk for surgery for the patient?

A) Urinary Tract infections

B) History of Premature Ventricle Beats
C) Abuse of street drugs
D) Hyperthyroidism
C) Abuse of street drugs

If a patient has a history of street drug abuse this puts them at risk in surgery. This
information is very important for the anesthesiologist due to the complications that can
arise from the anesthesia. All of the other options are important to note but not a risk for
surgery.
As a nurse, which statement is incorrect regarding an informed consent signed by a
patient?

A) The nurse can witness the client signing the consent

form
B) It is the nurse's responsibility to ensure the patient has
been educated by the physician about the procedure
before informed consent is obtained
C) Patients under 18 years of age may need a parent or
legal guardian to sign a consent form
D) The nurse is responsible for obtaining the consent for
surgery
D) The nurse is responsible for obtaining the consent for
surgery

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NCLEX Respiratory
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Gravity

A client has a closed chest drainage system in place. What should the nurse do to
determine the amount of chest tube drainage?

A. Refer to the date and time markings on the outside of the collection chamber.
B. Aspirate the drainage from the collection chamber.
C. Replace the existing system with a new one to access the drainage in the existing
system.
D. Clamp the chest tube and empty the fluid from the collection chamber.
A. Refer to the date and time markings on the outside of the collection chamber.
A client is admitted with suspected atelectasis. Which clinical
manifestation does the nurse expect to identify when assessing this
client?

A. Slow, deep respirations

B. Normal oral temperature
C. Dry, unproductive cough
D. Diminished breath sounds
D. Diminished breath sounds
1/51
Created by
Hayden48
Tags related to this set
Nursing
Saturated Solution Of Potassium Iodide
High Pressure Alarm
Increase Oral Fluid Intake

Terms in this set (51)

A client has a closed chest drainage system in place. What should the nurse do to
determine the amount of chest tube drainage?

A. Refer to the date and time markings on the outside of the collection chamber.
B. Aspirate the drainage from the collection chamber.
C. Replace the existing system with a new one to access the drainage in the existing
system.
D. Clamp the chest tube and empty the fluid from the collection chamber.
A. Refer to the date and time markings on the outside of the collection chamber.
A client is admitted with suspected atelectasis. Which clinical manifestation does the
nurse expect to identify when assessing this client?

A. Slow, deep respirations

B. Normal oral temperature
C. Dry, unproductive cough
D. Diminished breath sounds
D. Diminished breath sounds
A nurse is caring for a client with an endotracheal tube. Which is the most effective way
for the nurse to loosen respiratory secretions?

A. Increase oral fluid intake

B. Provide chest physiotherapy
C. Humidify the prescribed oxygen
D. Instill a saturated solution of potassium iodide
C. Humidify the prescribed oxygen
A client with a malignant parotid tumor is treated aggressively with radiation therapy and
surgery. Postsurgical arterial blood gas results are as follows: pH 7.32, PCO2 53 mm
Hg, and HCO3 25 mEq (25 mmol/L). The nurse should take which action?

A. Obtain a prescription and administer a diuretic.

B. Instruct the client to breathe into a rebreather bag at a slow rate.
C. Ask the client to cough forcefully and take deep breaths.
D. Obtain a prescription for sodium bicarbonate.
C. Ask the client to cough forcefully and take deep breaths.
A nurse is caring for a client with a history of chronic obstructive pulmonary disease
(COPD) who develops a pneumothorax and has a chest tube inserted. Which primary
purpose of the chest tube will the nurse consider when planning care?

A. Lessens the client's chest discomfort

B. Restores negative pressure in the pleural space
C. Drains accumulated fluid from the pleural cavity
D. Prevents subcutaneous emphysema in the chest wall
B. Restores negative pressure in the pleural space
A patient is admitted with a chest wound and experiencing extreme dyspnea,
tachycardia, and hypoxia. The chest wound is located on the left mid-axillary area of the
chest. On assessment, you note there is unequal rise and fall of the chest with absent
breath sounds on the left side. You also note a "sucking" sound when the patient
inhales and exhales. The patient's chest x-ray shows a pneumothorax. What type of
pneumothorax is this known as?

A. Closed pneumothorax
B. Open pneumothorax
C. Tension pneumothorax
D. Spontaneous pneumothorax
B. Open pneumothorax
In regards to the patient in the question above, which of the following options below is a
nursing intervention you would provide to this patient?

A. Place the patient in supine position

B. Place a non-occlusive dressing over the chest wound
C. Place a sterile occlusive dressing over the chest wound and tape it on three sides
D. Prepare the patient for a thoracentesis
C. Place a sterile occlusive dressing over the chest wound and tape it on three sides
A patient is diagnosed with a primary spontaneous pneumothorax. Which of the
following is NOT a correct statement about this type of pneumothorax?

A. It can be caused by the rupture of a pulmonary bleb.

B. It can occur in patients who are young, tall and thin without a history of lung disease.
C. Smoking increases the chances of a patient developing a spontaneous
pneumothorax.
D. It is most likely to occur in patients with COPD, asthma, and cystic fibrosis.
D. It is most likely to occur in patients with COPD, asthma, and cystic fibrosis.
Which of the following is a LATE sign of the development of a tension pneumothorax?

A. Hypotension
B. Tachycardia
C. Tracheal deviation
D. Dyspnea
C. Tracheal deviation
While caring for a patient with a suspected pneumothorax, you note there are several
areas on the patient's skin that appear to be "bulging" out. These "bulging" areas are
located on the patient's neck, face, and abdomen. On palpation on these areas, you
note they feel "crunchy". When charting your findings you would refer to this finding as?

A. Subcutaneous paresthesia
B. Pigment molle
C. Subcutaneous emphysema
D. Veisalgia
C. Subcutaneous emphysema
You're providing care to a patient with a pneumothorax who has a chest tube. On
assessment of the chest tube system, you note there is no fluctuation of water in the
water seal chamber as the patient inhales and exhales. You check the system for kinks
and find none. What is your next nursing action?

A. Keep monitoring the patient because this is a normal finding.

B. Increase wall suction to the system until the water fluctuates in the water seal
chamber.
C. Assess patient's lung sounds to assess if the affected lung has re-expanded.
D. Notify the physician.
C. Assess patient's lung sounds to assess if the affected lung has re-expanded.
A patient is receiving mechanical ventilation with PEEP. The patient had developed a
tension pneumothorax. Select ALL the signs and symptoms that can present with this
condition:

A. Hypotension
B. Jugular Venous Distention
C. Bradycardia
D. Tracheal deviation
E. Hyperemia
F. Tachypnea
A. Hypotension
B. Jugular Venous Distention
D. Tracheal deviation
F. Tachypnea
A patient has a chest tube for treatment of a pneumothorax in the left lung. Which
finding during your assessment requires immediate nursing intervention?

A. The water seal chamber has intermittent bubbling.

B. The patient has slight tracheal deviation to the right side.
C. The water seal chamber fluctuates while the patient inhales and exhales.
D. The patient complains of tenderness at the chest tube insertion site.
B. The patient has slight tracheal deviation to the right side.
Which statement is CORRECT about a tension pneumothorax?

A. This condition happens when an opening to the intrapleural space creates a two-way
valve which causes pressure to build up in the space leading to shifting of the
mediastinum.
B. A tension pneumothorax is a medical emergency and is treated with needle
decompression.
C. Tracheal deviation is an early sign of a tension pneumothorax
D. An open pneumothorax is the only cause of a tension pneumothorax.
B. A tension pneumothorax is a medical emergency and is treated with needle
decompression.
A patient receiving treatment for a pneumothorax calls on the call light to tell you
something is wrong with their chest tube. When you arrive to the room you note that the
drainage system has fallen on its side, and there is a large crack in the system. What is
your next PRIORITY?

A. Place the patient in supine position and clamp the tubing.

B. Notify the physician immediately.
C. Disconnect the drainage system and get a new one.
D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a
bottle of sterile water and obtain a new system.
D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a
bottle of sterile water and obtain a new system.
A nurse is caring for a client with a Venturi mask who is receiving 40% oxygen. What
nursing actions are indicated? Select all that apply.

A. Keep the oxygen source higher than the client's airway.

B. Adjust the liter flow according to the oxygen saturation.
C. Prevent the client's blanket from covering the adaptor's orifices.
D. Ensure that the bag does not deflate completely during inspiration.
E. Check that the appropriate adaptor to deliver the prescribed FiO2 is attached to the
mask.
C. Prevent the client's blanket from covering the adaptor's orifices
E. Check that the appropriate adaptor to deliver the prescribed FiO2 is attached to the
mask.
Endotracheal intubation and positive-pressure ventilation are instituted because of a
client's deteriorating respiratory status. What is the priority nursing intervention?

A. Facilitate verbal communication

B. Prepare the client for emergency surgery
C. Maintain sterility of the ventilation system
D. Assess the client's response to the mechanical ventilation
D. Assess the client's response to the mechanical ventilation
While walking in a hallway, a client with a chest tube becomes confused and pulls the
chest tube out. What is the nurse's immediate action?
A. Place the client in the supine position
B. Spread a clamp in the insertion site to hold the site open
C. Obtain a sterile Vaseline gauze to cover the opening
D. Cover the opening with the cleanest material available
D. Cover the opening with the cleanest material available
What response provides evidence that a client with chronic obstructive pulmonary
disease (COPD) understands the nurse's instructions about an appropriate breathing
technique?

A. Inhales through the nose with the mouth closed

B. Increases the respiratory rate
C. Holds each breath for a second at the end of inspiration
D. Progressively increases the length of the inspiratory phase
C. Holds each breath for a second at the end of inspiration
The nurse provides teaching to a client who will begin to receive tube feedings after a
total laryngectomy. The nurse concludes that the teaching was understood when the
client makes which statement about tube feedings?

A. "I will need tube feedings until healing of the incision is complete."
B. "I will need tube feedings until the gag reflex returns."
C. "I will need tube feedings until the ability to belch is restored."
D. "I will need tube feedings until my oral feedings can be digested."
A. "I will need tube feedings until healing of the incision is complete."
Which preoperative and postoperative care points should be included when providing
education and intervention to a client scheduled for a septoplasty? Select all that apply.

A. Teach the client about hot compresses.

B. Encourage the client to quit smoking before surgery.
C. Observe the surgical site for edema.
D. Teach the client about post-surgery activities that are restricted.
E. Assess the client's respiratory status.
F. Encourage the client to take aspirin before the surgery.
B. Encourage the client to quit smoking before surgery.
C. Observe the surgical site for edema.
D. Teach the client about post-surgery activities that are restricted.
E. Assess the client's respiratory status.
A nurse provides smoking-cessation education to a client with chronic obstructive
pulmonary disease (COPD). The nurse concludes that the client is ready to quit
smoking when the client makes which statement?

A. "I'll just finish the carton that I have at home."

B. "I'll cut back to a half pack a day."
C. "I find that smoking is the only way I can relax."
D. "I should find this easy because I don't smoke when I drink."
B. "I'll cut back to a half pack a day."
A client arrives in the emergency department with multiple crushing wounds of the
chest, abdomen, and legs. Which are the priority nursing assessments?

A. Level of consciousness and pupil size

B. Characteristics of pain and blood pressure
C. Quality of respirations and presence of pulses
D. Observation of abdominal contusions and other wounds
C. Quality of respirations and presence of pulses
A client complaining of fatigue is admitted to the hospital with a diagnosis of chronic
obstructive pulmonary disease (COPD). What should the nurse do to prevent fatigue?

A. Provide small, frequent meals

B. Encourage pursed-lip breathing
C. Schedule nursing activities to allow for rest
D. Encourage bed rest until energy level improves
C. Schedule nursing activities to allow for rest
Which method of oxygen delivery should a nurse anticipate will be prescribed for a
client with a pulse oximetry reading of 65%?

A. Face tent
B. Venturi mask
C. Nasal cannula
D. Nonrebreather mask
D. Nonrebreather mask
A client is brought to the emergency department with deep partial-thickness burns on
the face and full-thickness burns on the neck, entire anterior chest, and one arm. To
assess for heat inhalation, the nurse first should observe for which finding?

A. Changes in the chest x-ray findings

B. Sputum that contains particles of blood
C. Nasal discharge containing carbon particles
D. Changes in the arterial blood gases consistent with acidosis
C. Nasal discharge containing carbon particles
A client has a bronchoscopy in the ambulatory surgery unit. Which action should the
nurse take to prevent laryngeal edema?

A. Place ice chips in the client's mouth

B. Offer liberal amounts of fluid to the client
C. Keep the client in the semi-Fowler position
D. Tell the client to suck on medicated lozenges
C. Keep the client in the semi-Fowler position
Which condition can cause a client's partial pressure of end-tidal carbon dioxide
(PETCO2) to be 50 mmHg?

A. Hypoventilation
B. Tracheal extubation
C. Pulmonary embolism
D. Total airway obstruction
A. Hypoventilation
A nurse is teaching Hands Only Basic Life Support for adults in the community. What
should the rescuer do first after determining that the person is not responding and the
emergency medical system has been activated?

A. Identify the absence of pulse.

B. Give two rescue breaths with a CPR mask.
C. Perform the head tilt-chin lift maneuver.
D. Perform chest compression at a rate of 100/min.
D. Perform chest compression at a rate of 100/min.
A client with acute respiratory distress syndrome is intubated and placed on a ventilator.
What should the nurse do when caring for this client and the mechanical ventilator?

A. Deflate the cuff on the endotracheal tube for a few minutes every one to two hours.
B. Assess the need for suctioning when the high-pressure alarm of the ventilator is
activated.
C. Adjust the temperature of fluid in the humidification chamber depending on the
volume of gas delivered.
D. Regulate the positive end-expiratory pressure (PEEP) according to the rate and
depth of the client's respirations.
B. Assess the need for suctioning when the high-pressure alarm of the ventilator is
activated.
The nurse is caring for a client who is hyperventilating. The nurse recalls that the client
is at risk for what?

A. Respiratory acidosis
B. Respiratory alkalosis
C. Respiratory compensation
D. Respiratory decompensation
B. Respiratory alkalosis
Which findings should the nurse expect to see in a client with chronic obstructive
pulmonary disease? Select all that apply.

A. Elevated levels of partial arterial oxygen

B. Elevated levels of eosinophils
C. Elevated levels of neutrophils
D. Elevated levels of red blood cells
E. Elevated levels of peripheral capillary oxygen saturation
B. Elevated levels of eosinophils
C. Elevated levels of neutrophils
D. Elevated levels of red blood cells
A nurse is involved in an international committee to address global health problems.
What suggestion is most appropriate for the nurse to make to best meet the challenge
associated with a potential emerging influenza pandemic?
A. Stockpile antibiotics.
B. Establish a global surveillance plan.
C. Limit vaccination programs to school-aged children.
D. Initiate vaccination programs during the months of August and September.
B. Establish a global surveillance plan.
The nurse is caring for a client who has a peripherally inserted central catheter (PICC).
The client notifies the nurse that the catheter got tangled up in bedclothes and came
out. What should the nurse do first?

A. Inspect the catheter

B. Notify the healthcare provider
C. Clamp the remaining device
D. Assess respiratory status
A. Inspect the catheter
A 65-year old client is found to have dilatation of the bronchioles and alveolar ducts.
Which suggestions of the nurse would help the client overcome this situation? Select all
that apply.

A. Suggest the use of incentive spirometry.

B. Suggest that the client takes an adequate amount of calcium daily.
C. Suggest that the client perform vigorous pulmonary hygiene activities.
D. Suggest that the client maintain an upright position as much as possible.
E. Suggest that the client talk face-to face with others as much as possible.
A. Suggest the use of incentive spirometry.
C. Suggest that the client perform vigorous pulmonary hygiene activities.
D. Suggest that the client maintain an upright position as much as possible.
The nurse is caring for a client who had a wedge resection of a lobe of the lung and now
has a chest tube with a three-chamber underwater drainage system in place. Which
main purpose of the third chamber of the underwater drainage system should the nurse
consider when planning care?

A. Acts as a drainage container

B. Provides an airtight water seal
C. Controls the amount of suction
D. Allows for escape of air bubbles
C. Controls the amount of suction
A client with a history of hemoptysis and cough for the last six months is suspected of
having lung cancer. A bronchoscopy is performed. Two hours after the procedure the
nurse identifies an increase in the amount of bloody sputum. What is the nurse's
priority?

A. Immediately contact the primary healthcare provider

B. Document the amount of sputum
C. Monitor vital signs every hour
D. Increase the frequency of coughing and deep breathing
A. Immediately contact the primary healthcare provider
The nurse observes a client with chronic obstructive pulmonary disease (COPD)
breathing rapidly and using accessory muscles of respiration. The nurse auscultates the
lungs and hears crackles and wheezes. What action should the nurse take?

A. Encourage the client to take slow, deep breaths and administer 5 L/min oxygen per
nasal cannula.
B. Place the client in a side-lying position and perform chest physiotherapy using
clapping and vibration.
C. Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen
per nasal cannula.
D. Assist the client in assuming a position of comfort and perform postural drainage.
C. Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen
per nasal cannula.
A nurse is caring for a client who experienced a crushing chest injury. A chest tube is
inserted. Which observation indicates a desired response to this treatment?

A. Increased breath sounds

B. Increased respiratory rate
C. Crepitus detected on palpation of the chest
D. Constant bubbling in the drainage collection chamber
A. Increased breath sounds
A nurse is caring for a client with the diagnosis of emphysema, a chronic obstructive
pulmonary disease (COPD). The client is hypoxemic and also has chronic hypercarbia.
Which statement reflects the oxygen needs of this client?

A. The client may need up to 60% oxygen flow via Venturi mask.
B. The client requires lower levels of oxygen delivery, usually 1 to 3 L/min via nasal
cannula.
C. The client should receive humidified oxygen delivered by a face mask.
D. The client's respiratory treatment plan should have oxygen eliminated from it.
B. The client requires lower levels of oxygen delivery, usually 1 to 3 L/min via nasal
cannula.
A client with a tentative diagnosis of lung cancer is scheduled for a mediastinoscopy
with biopsy. Which is a priority nursing action?

A. Tell the client that chest tubes will be present after the procedure.
B. Explain that the procedure will allow visualization of lungs and chest cavity.
C. Inform the client that some pleural fluid will be removed during this procedure.
D. Advise the client to avoid eating or drinking anything for several hours before the
test.
D. Advise the client to avoid eating or drinking anything for several hours before the
test.
Select ALL the options that are TRUE about chronic bronchitis and emphysema:

A. Patients with chronic bronchitis have the ability to fully exhale but have limited
airflow.
B. Emphysema and chronic bronchitis are irreversible.
C. An incentive spirometer is used to diagnose both chronic bronchitis and emphysema.
D. Patients with chronic bronchitis are sometimes referred to as "blue bloaters, while
patients with emphysema are sometimes referred to as "pink puffers".
B. Emphysema and chronic bronchitis are irreversible.
D. Patients with chronic bronchitis are sometimes referred to as "blue bloaters, while
patients with emphysema are sometimes referred to as "pink puffers".
True or False: Patients with emphysema experience hypoventilation as a compensatory
mechanism to help increase oxygen levels and decrease carbon dioxide levels in the
body.
False
Which of the following is most commonly found in a patient with emphysema?

A. Barrel chest
B. Cyanosis
C. V/Q mismatch
D. Excessive productive cough
A. Barrel chest
In which of the following conditions below is there a matched V/Q defect?

A. Chronic Bronchitis
B. Emphysema
B. Emphysema
True or False: V/Q mismatch is found in chronic bronchitis.
True
Which of the following is NOT a treatment for chronic bronchitis or emphysema?

A. Albuterol
B. Spirvia
C. Theophylline
D. Metoprolol
D. Metoprolol
In which of the following conditions below do the alveolar sacs lose elasticity which can
lead to "air-trapping":

A. Chronic Bronchitis
B. Emphysema
B. Emphysema
Patients with chronic bronchitis and emphysema can MOST COMMONLY experience
what type of acid-base imbalance?

A. High oxygen level and high carbon dioxide level

B. Low oxygen level and low carbon dioxide level
C. High oxygen level and low carbon dioxide level
D. Low oxygen level and high carbon dioxide level
D. Low oxygen level and high carbon dioxide level
Which of the following is NOT a sign and symptom of chronic bronchitis?

A. Productive cough
B. Shortness of breath
C. Cyanosis
D. Barrel chest
D. Barrel chest
True or False: Hyperinflation of the lungs leads to diaphragm flattening.
True

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Chest Tube 2
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Gravity

The anatomical structure located in the center of the thoracic

cavity is the:

1. Diaphragm
2. Visceral Pleura
3. Parietal Pleura
4. Mediastinum
4 - Mediastinum
Which of the following statements is true about intrapleural (the space between
the parietal and visceral or pulmonary pleurae) pressure under normal
conditions?

1. It is positive during inhalation; negative during exhalation.

2. It is negative during inhalation; positive during exhalation.
3. It is always negative.
4. It is always positive.
3 - It is always negative.
1/11

Created by
jeffrey_urbach
Tags related to this set
Suction Control Chamber
Water Seal Chamber
Pressure Relief Valve

Terms in this set (11)

The anatomical structure located in the center of the thoracic cavity is the:

1. Diaphragm
2. Visceral Pleura
3. Parietal Pleura
4. Mediastinum
4 - Mediastinum
Which of the following statements is true about intrapleural (the space between the parietal and
visceral or pulmonary pleurae) pressure under normal conditions?

1. It is positive during inhalation; negative during exhalation.

2. It is negative during inhalation; positive during exhalation.
3. It is always negative.
4. It is always positive.
3 - It is always negative.
A pt with an opening in the chest wall, such as from a gunshot, stab wound or implament,
resulting in "sucking chest wound" can be said to have:

1. An open pneumothorax.
2. A Pleural effusion.
3. A hemothorax.
4. A closed pneumothorax.
1 - An open pneumothorax.
A potentially life-threatening condition in which air and pressure rapidly accumulate in the
pleural space and, if not treated, can result in a mediastinal shift is called:

1. A spontaneous pneumothorax.
2. An open pneumothorax.
3. An iatrogenic pneumothorax.
4. A tension pneumothorax.
4 - A tension pneumothorax.
A potentially life-threatening condition in which blood collects around the heart, particularly
after heart surgery or chest trauma, is called:

1. Mediastinal shift.
2. Mediastinal effusion.
3. Cardiac insufficiency.
4. Cardiac Tamponade.
4 - Cardiac Tamponade.
The most important element in a chest drainage system is:

1. The suction source.

2. The suction control.
3. The collection bottle/ chamber.
4. The water seal.
4 - The water seal.
In self-contained, disposable chest drains, the manual high negative pressure relief valve:

1. Alerts the nurse to high suction levels accumulating in the system.

2. Allows filtered atmospheric air into the system to offset a rise in negative pressure.
3. Allows water to be added to the system without disconnecting the pt tubing.
4. Alerts the nurse to a situation of high pressure within the system and automatically vents.
2 - Allows filtered atmospheric air into the system to offset a rise in negative pressure.
In a self-contained, disposable chest drain, the amount of negative pressure transmitted to the pt
by suction is determined by:

1. The amount of suction set on the wall vacuum regulator.

2. The sensitivity of the high negative pressure relief valve.
3. The level of water in the water seal chamber.
4. The level of water in the suction control chamber.
4 - The level of water in the suction control chamber.
A physician has just performed a thoracostomy for a pleural effusion. The nurse handed the pt
tubing from the drain to the physician, who attached it to the chest tube. The drain is properly
filled with water and placed in an upright position below the pt's chest. The physician orders
suction to the chest drain system. With a water-filled suction control chamber, how should the
nurse adjust the vacuum source?

1. Adjust the vacuum source until the dial on the vacuum regulator reads -20mmHg.
2. Adjust the vacuum source until constant, gentle bubbling just begins in the suction control
chamber.
3. Adjust the vacuum source until there is vigorous bubbling in the suction control chamber.
4. Adjust the vacuum source until there is bubbling in the water seal chamber.
2 - Adjust the vacuum source until constant, gentle bubbling just begins in the suction control
chamber.
Which of the following situations is likely to result in an absence of fluctuations in the chest
drainage tubing?

1. The tubing is coiled on the bed with a straight path to the chest drain.
2. The pt is receiving positive pressure ventilation.
3. The tubing is blocked in some way.
4. The pt is ambulatory.
3 - The tubing is blocked in some way.
New bubbling is observed in the water seal chamber after a pt with a pleural chest tube returns
from radiology. The nurse clamps the chest tube momentarily with a tubing clamp at the dressing
site. When this is done, bubbling in the water seal stops. The next appropriate nursing action is
to:

1. Remove the chest tube dressing to see if one or more eyelets of the chest tube have been
pulled out of the chest.
2. Call the physician immediately and do not leave the pt's bedside because of the risk of
respiratory failure.
3. Do nothing. This bubbling is normal in pts with pleural chest tubes.
4. Continue to monitor the water seal chamber for bubbling every hour for the next four hours.
1 - Remove the chest tube dressing to see if one or more eyelets of the chest tube have been
pulled out of the chest.

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Chest Tube NCLEX questions
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Gravity

You are providing care to a patient with a chest tube. On assessment of the drainage system, you
note continuous bubbling in the water seal chamber and oscillation. Which of the following is the
CORRECT nursing intervention for this type of finding?
A. Reposition the patient because the tubing is kinked.
B. Continue to monitor the drainage system.
C. Increase the suction to the drainage system until the bubbling stops.
D. Check the drainage system for an air leak.

D
A patient is receiving positive pressure mechanical ventilation and has a chest
tube. When assessing the water seal chamber what do you expect to find?*
A. The water in the chamber will increase during inspiration and decrease during
expiration.
B. There will be continuous bubbling noted in the chamber.
C. The water in the chamber will decrease during inspiration and increase during
expiration.
D. The water in the chamber will not move.
C
1/9
Created by
francis_j_crupi
Tags related to this set
Nursing
Chest Tube Drainage System
Water Seal Chamber
Suction Control Chamber

Terms in this set (9)

You are providing care to a patient with a chest tube. On assessment of the drainage
system, you note continuous bubbling in the water seal chamber and oscillation. Which
of the following is the CORRECT nursing intervention for this type of finding?
A. Reposition the patient because the tubing is kinked.
B. Continue to monitor the drainage system.
C. Increase the suction to the drainage system until the bubbling stops.
D. Check the drainage system for an air leak.
D
A patient is receiving positive pressure mechanical ventilation and has a chest tube.
When assessing the water seal chamber what do you expect to find?*
A. The water in the chamber will increase during inspiration and decrease during
expiration.
B. There will be continuous bubbling noted in the chamber.
C. The water in the chamber will decrease during inspiration and increase during
expiration.
D. The water in the chamber will not move.
C
What type of chest tube system does this statement describe? This chest drainage
system has no water column to control suction but uses a suction monitor bellow that
balances the wall suction and you can adjust water suction pressure using the rotary
suction dial on the side of the system. It allows for higher suction pressure levels, has
no bubbling sounds, and water does not evaporate from it as with other systems.*
A. Mediastinal chest tube system
B. Dry suction chest tube system
C. Wet suction chest tube system
D. Dry-Wet suction chest tube system
B
The patient in room 2569 calls on the call light to tell you something is wrong with his
chest tube. When you arrive to the room you note that the drainage system has fallen
on its side and is leaking drainage onto the floor from a crack in the system. What is
your next PRIORITY?*
A. Place the patient in supine position and clamp the tubing.
B. Notify the physician immediately.
C. Disconnect the drainage system and get a new one.
D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a
bottle of sterile water and obtain a new system.
D
You're assessing a patient who is post-opt from a chest tube insertion. On assessment,
you note there is 50 cc of serosanguinous fluid in the drainage chamber, fluctuation of
water in the water seal chamber when the patient breathes in and out, and bubbling in
the suction control chamber. Which of the following is the most appropriate nursing
intervention?*
A. Document your findings as normal.
B. Assess for an air leak due to bubbling noted in the suction chamber.
C. Notify the physician about the drainage.
D. Milk the tubing to ensure patency of the tubes.
A
A patient is recovering from a pneumothorax and has a chest tube present. Which of the
following is an appropriate finding when assessing the chest tube drainage system?*
A. Intermittent bubbling may be noted in the water seal chamber.
B. 200 cc of drainage per hour is expected during recovery of a pneumothorax.
C. The chest tube is positioned at the patient's chest level to facilitate drainage.
D. All of these options are appropriate findings
A
While helping a patient with a chest tube reposition in the bed, the chest tube becomes
dislodged. What is your immediate nursing intervention?*
A. Stay with the patient and monitor their vital signs while another nurse notifies the
physician.
B. Place a sterile dressing over the site and tape it on three sides and notify the
physician.
C. Attempt to re-insert the tube.
D. Keep the site open to air and notify the physician.
B
A patient is about to have their chest tube removed by the physician. As the nurse
assisting with the removal, which of the following actions will you perform? Select-all-
that-apply:*
A. Educate the patient how to take a deep breath out and inhale rapidly while the tube in
being removed.
B. Gather supplies needed which will include a petroleum gauze dressing per physician
preference.
C. Place the patient in Semi-Fowler's position.
D. Have the patient take a deep breath, exhale, and bear down during removal of the
tube.
E. Pre-medicate prior to removal as ordered by the physician.
F. Place the patient is prone position after removal.
BCDE
A patient with a chest tube has no fluctuation of water in the water seal chamber. What
could be the cause of this?*
A. This is an expected finding.
B. The lung may have re-expanded or there is a kink in the system.
C. The system is broken and needs to be replaced.
D. There is an air leak in the tubing.
B

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Cardiac/Respiratory Exam
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Gravity

A physician has just performed a thoracostomy for a pleural effusion. The nurse
handed the patient tubing from the drain to the physician, who attached it to the
chest tube. The drain is properly filled with water and placed in an upright
position below the patient's chest. The physician orders suction to the chest drain
system. With a dry suction control chamber (as is present in the Atrium Oasis),
how should the nurse adjust the vacuum source?
Adjust the vacuum source until the bellows indicator reaches the arrow mark in the indicator window
Which of the following statements is true regarding patient movement while requiring chest
drainage? (assume a physician order or protocol exists)
Patients may walk around once the nurse disconnects the drain from suction as long as the drain
remains below the chest
1/40

Created by
Ms_M53
Tags related to this set
Suction Control Chamber
Distant Heart Sounds
Sucking Chest Wound

Terms in this set (40)

A physician has just performed a thoracostomy for a pleural effusion. The nurse handed
the patient tubing from the drain to the physician, who attached it to the chest tube. The
drain is properly filled with water and placed in an upright position below the patient's
chest. The physician orders suction to the chest drain system. With a dry suction control
chamber (as is present in the Atrium Oasis), how should the nurse adjust the vacuum
source?
Adjust the vacuum source until the bellows indicator reaches the arrow mark in the
indicator window
Which of the following statements is true regarding patient movement while requiring
chest drainage? (assume a physician order or protocol exists)
Patients may walk around once the nurse disconnects the drain from suction as long as
the drain remains below the chest
If the chest tube is pulled out of the patient's chest, and the patient had an air leak from
the lung, after asking a colleague to call a physician STAT, emergency nursing
management is to:
Cover the opening with a sterile dressing, taped on three sides
Which of the following situations is likely to result in an absence of fluctuations in the
chest drainage tubing?
The tubing is blocked in some way
New bubbling is observed in the water seal chamber after a patient with a pleural chest
tube returns from a test. The nurse clamps the chest tube momentarily with a tubing
clamp at the dressing site. When this is done, bubbling in the water seal stops. The next
appropriate nursing action is to:
Remove the chest tube dressing to see if one or more eyelets of the chest tube have
been pulled out of the chest
When is it beneficial to clamp a patient's chest tube?
When ordered by a physician to simulate tube removal and assess the patient's
response
Which of the following signs indicates a chest tube may be removed?
Bubbling in the water seal has been absent for 24 hours following iatrogenic
pneumothorax from CVP placement
The water seal is the most important element of the drainage system because:
. It allows air to exit the pleural space but prevent air from entering the pleural space
through the chest tube
The following would result in a loss of the water seal:
Evaporation of the water in the water seal chamber below the 2 cm mark.
The anatomical structure located in the center of the thoracic cavity is the:
Mediastinum
Which of the following statements is true about intrapleural (the space between the
parietal and visceral or pulmonary pleurae) pressure under normal conditions?
it is always negative
A patient with an opening in the chest wall, such as from a gunshot, stab wound or
impalement, resulting in "sucking chest wound" can be said to have:
An open pneumothorax
A potentially life-threatening condition in which air and pressure rapidly accumulate in
the pleural space and, if not treated, can result in a mediastinal shift is called:
A tension pneumothorax
In self-contained, disposable chest drains, the manual high negative pressure relief
valve
Allows filtered atmospheric air into the system to offset a rise in negative pressure
In a self-contained, disposable chest drain, the amount of negative pressure transmitted
to the patient by suction is determined by:
The dial setting on the suction control chamber
the following would result in the loss of the water seal:
evaporation of the water in the water seal chamber below the 2cm mark
when a patient has experienced a pneumothorax, chest auscultation reveals
bilateral unequal breath sounds with no breath sounds over the affected area
which are signs of respiratory distress?
abdominal breathing, SaO2 89%
Which are routes in which the anthrax bacterium may enter the body?
lungs
skin
intestine
interventions that contribute to comfort in patients experiencing dyspnea include:
breathing exercises
acupuncture
visualization
massage
identify the purposes of chest drainage
drains air, blood, fluid from pleural space
restores positive pressure in chest cavity
allows route for medication administration
pericarditis
inflammation of the membrane that surrounds the heart (pericardium)
pericarditis auscultation
Pericardia friction rub- this is a high pitched scratchy sound heard with the diaphragm of
the stethoscope
pericarditis possible cause
IV drug use
cocaine use
pericarditis s/s
pulsus paradoxus - a decrease in the SBP upon inspiration less than 10 mm Hg
fever
tachycardia
hypotension
restlessness
pericarditis may lead to
cardiac tamponade - excessive accumulation of fluid in the pericardial space
cardiac tamponade sounds like
muffled or distant heart sounds
cardiac tamponade is treated with a
pericardiocentesis
Infective endocarditis
inflammation of the inner lining (endocardium) of the heart
endocarditis s/s
low grade fever
petechial rash
splenomegaly
splinter hemorrhages - black lines under nails
osler nodes - painful nodes on fingers and toes
janeway lesions - red/blue on soles of feet
for treatment of endocarditis
In the initial treatment the pt should be on bed rest with bathroom privilege only-reduce
the workload on the heart
valves are responsible for
maintaining one way direction
after a valve replacement, a patient will need to be on anticoagulants
for life
if a patient is experiencing v tach
give them a banana to increase their potassium levels
if there is a sinus problem in the heart
the atrial are involved
chest tubes reestablish
negative pressure and re-expands lungs
bubbling in the water seal chamber indicates
air leak
the amount of water in the water seal chamber controls
suction to lungs
chest tube management
keep below level of chest
reports level over 100mL/hr
measure fluid levels
change when full
NEVER CLAMP - if broken, place distal end in sterile water
prior to removal
premedicate the patient
valsalva manuever during removal
occlusive dressing applied

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