Answer Key for Chest Tubes PDF

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Perry: Clinical Nursing Skills & Techniques, 9th Edition ANSWER KEY FOR CHEST TUBES MODULE P OST TESTS AND EXAM (Since questions may be reordered with each usage, the question number in the answer key may not correspond to the number that the student reports for a particular quiz item). Lesson 1 Post Test 1. Which of the following tasks associated with a chest tube is the responsibility of the nurse? a) Obtaining informed consent prior to the procedure b) Removing the chest tube when the order is received c) Setting up the equipment, positioning the patient positioning, and monitoring patient status d) Inserting the chest tube, connecting it to a drainage system, and monitoring output Correct answer: c Rationale: The nurse is responsible for assisting during a chest tube insertion. This includes being responsible for setting up equipment, positioning a patient, and monitoring the patient’s status before, during, and after the procedure. It is the responsibility of the physician to obtain informed consent from the patient before inserting a chest tube. The nurse should verify the presence of a signed informed consent document before the start of the procedure. It is the responsibility of the physician or NAP to remove the chest tube. Physicians are usually responsible for the insertion of chest tube catheters. 2. A patient is being prepared for open-heart surgery. Where would you expect the chest tube to be located when the patient returns from surgery? a) In the second or third intercostal space b) In the mediastinum just below the sternum c) In the fifth or sixth intercostal space d) Posteriorly or laterally Correct answer: b Rationale: A mediastinal chest tube is placed in the mediastinum just below the sternum. Mediastinal chest tubes are inserted for open-heart surgery patients to drain fluid away from the pericardial sac. The second or third intercostal space is the common location for a chest tube inserted to resolve a pneumothorax. A chest tube located in the fifth or sixth intercostals space either posteriorly or laterally is the typical placement to remove blood or fluid as with a hemothorax.

3. A student nurse is working as a tutor for a group of freshman physiology students. Which statement, if made by someone in the study group, would require correction? a) “Normally, atmospheric pressure in the pleural space is negative ( -4 to -10 mm Hg).” b) “Besides difficulty breathing, an indication of a tension pneumothorax is a shift of the

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contents in the mediastinum (e.g., trachea and heart) to the opposite ( unaffected) side of the chest.” c) “Kinking or clamping of the chest tube can result in a tension pneumothorax.” d) “Physiologically, inspiration requires less work than expiration.” Correct answer: d Rationale: The act of inspiration involves more muscles and effort than expiration. Expiration is a passive activity, while inspiration requires the muscles to push against negative pressure in the pleural cavity. Atmospheric pressure in the pleural space is normally negative (-4 to -10 mm Hg). Besides breathing difficulty, another indication of a tension pneumothorax is a shift of the contents in the mediastinum (e.g., trachea and heart) to the opposite (unaffected) side of the chest. Tension pneumothorax can also be caused by mechanical ventilation, cardiopulmonary resuscitation (CPR), and prolonged occlusion of chest tubes, such as obstruction of the chest tube by a blood clot. Patients with chest trauma, fractured ribs, invasive thoracic bedside procedures (such as insertion of central lines), and those on high-pressure mechanical ventilation are at risk for tension pneumothorax.

4. A patient’s family member asks what causes the patient’s lung to collapse. The nurse’s best response is a) “When the intactness of the pleural space is broken, the space fills with air and/or fluid, causing positive thoracic pressure, which collapses lung tissue.” b) “The exact cause remains unknown, but it is thought a collapsed lung may occur as a result of a weakened diaphragm.” c) “Several factors can cause a lung to collapse, such as an increase in fibrous lung tissue, especially in the patient who smokes.” d) “The negative pressure between the parietal pleura and the visceral pleura becomes too great.” Correct answer: a Rationale: Normally, atmospheric pressure in the pleural space is negative (i.e., -4 to -10 mm Hg). When the integrity of the pleural space is interrupted, the space fills with air and/or fluid, thereby causing positive thoracic pressure, which collapses lung tissue. Though the exact cause remains unknown, a collapsed lung may occur as a result of a weakened diaphragm. Several factors may cause a lung to collapse (e.g., increased fibrous lung tissue). 5. A patient suddenly becomes short of breath, is complaining of chest pain, and has a fall in blood pressure. The nurse auscultates the lung sounds and hears normal lung sounds on the left as well as very diminished lung sounds on the right. The patient’s trachea appears to be deviated to the left. What should the nurse suspect? a) The patient has an open pneumothorax b) The patient has a hemothorax c) The patient has a pneumohemothorax d) The patient has a tension pneumothorax Correct answer: d Copyright © 2018, Elsevier Inc. All rights reserved.

Answer Key for Chest Tubes Rationale: The patient most likely has a tension pneumothorax as evidenced by the shift in mediastinal contents. 6. Match the correct term to the corresponding diagram. Correct match:

Tension pneumothorax

Closed pneumothorax

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Hemothorax

Open pneumothorax Rationale: A pneumothorax is a collection of air in the pleural space causing a collapse of lung tissue. A closed pneumothorax occurs when air enters the pleural cavity through a perforation in the pleura covering the lung, such as with the rupture of an emphysematous bleb or superficial lung abscess. An open pneumothorax occurs when the air enters through a perforation of the chest wall, such as the result of chest trauma, an automobile accident, a gunshot wound, or a stab wound. A tension pneumothorax occurs when air enters the pleural space but cannot escape via the route of entry. The increased positive pressure in the pleural space results in the collapse of lung tissue. If left untreated, this pressure builds up, causing a complete collapse of the lung. In addition, the contents of the mediastinum shift, and the pressure from these contents places pressure on the heart and great vessels, such as the vena cava. In turn, this pressure results in a decreased venous return and subsequent cardiac output. A hemothorax is an accumulation of blood and fluid in the pleural cavity between the parietal and visceral pleura, usually as a result of trauma. If left untreated, the accumulation of blood in the pleural space collapses lung tissue and ultimately affects cardiac output.

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Lesson 2 Post Test 1. A patient has returned from the operating room with a chest tube in his sixth intercostal space with orders to connect the patient to wall suction. The patient has a three-chamber, water-seal system. Eight hours later you find the patient complaining of increased chest pain, a respiratory rate of 40 breaths per minute, and a pulse of 110. The water-seal chamber is dry. The patient is in obvious distress. What should you suspect as the primary cause? a) The patient’s chest tube has become dislodged. b) There is no water in the water-seal chamber. c) The wall suction is too low. d) The patient is breathing shallowly and avoiding coughing. Correct answer: b Rationale: The water seal is dry allowing air to enter the chest and preventing the lung from expanding. The level of water in the suction control chamber maintains the level of suction. 2. What effect will increasing the wall suction have on a three-chamber, water-seal chest tube drainage system connected to suction? a) It will increase the rate of lung expansion. b) It will create more vigorous bubbling and faster evaporation of water. c) It will increase the frequency of emptying the drainage collection device. d) It will damage lung tissue if the negative pressure is too great. Correct answer: b Rationale: Increasing wall suction creates more vigorous (and louder) bubbling and faster evaporation of water from the chamber. The level of water in the suction control compartment maintains the level of suction. The rate of lung reexpansion may be affected by a low water level (as fluid level decreases the amount of suction also decreases) or by a drainage system that is too full and needs emptying. The chest tube drainage system has a built-in release valve to prevent tissue damage. If the suction source delivers more negative pressure than the suction control chamber water level allows, atmospheric air is pulled into the suction control chamber through an inlet, causing the excess suction to dissipate. 3. The nurse is monitoring the functioning of a three-chamber, water-seal drainage system. Which of the following would negatively affect the functioning of this type of chest tube drainage system? (Select all that apply.) a) Evaporation in the water-seal chamber b) Evaporation in the suction control chamber c) Evaporation in the collection chamber d) If the drainage system is tipped over Correct answer: a, b, d Rationale: It is the level of water that maintains suction pressure. The nurse must be alert to the level of sterile water or normal saline in the water-seal or suction control chamber and be able to replace it as necessary to maintain proper functioning of the system. If the system is tipped or

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Answer Key for Chest Tubes falls over, the integrity of the water-seal can be affected. The drainage system must remain upright to function properly. 4. Match the correct features to the correct drainage system. Correct match: A waterless, three-chamber Has suction capability, a collect chamber, and a chest tube drainage system leak indicator A three-chamber, water-seal Has one water-seal chamber, one suction chest drainage system chamber, and one drainage chamber A two-chamber, water-seal Has one water-seal chamber and one collection system chamber Rationale: A three-bottle ,water-seal system contains one water-seal chamber, one suction chamber, and one drainage chamber. A two-bottle, water-seal system is composed of one waterseal chamber and one collection chamber. A waterless chest tube drainage system has suction capability, a collection chamber, and a leak indicator. 5. Match the correct situation to the correct drainage system. Correct match: A two-chamber, water-seal drainage system Pneumohemothorax Hemothorax with suction ordered Pneumothorax

A three-chamber, water-seal drainage system A single-chamber, water-seal drainage system

Rationale: A single-bottle, water-seal drainage system is designed for removal of air, as with a pneumothorax. A two-bottle, water-seal drainage system can be used to drain both fluid and air. When suction is required, a three-bottle (chamber), water-seal drainage system may be used. 6. The nurse is looking at the front of a waterless chest drainage system. Which of the following would be cause for concern? a) After 2 to 3 days, tidaling stops. b) Gentle tidaling is present in the diagnostic air-leak indicator. c) Continuous bubbling is present. d) There is approximately 15 mL of fluid in the diagnostic air-leak indicator. Correct answer: c Rationale: Bubbling indicates the presence of an air leak, which must be identified and treated. The lung is reexpanding normally when a gentle tidaling is present in the diagnostic air-leak indicator. If after 2 to 3 days tidaling stops, the lung is usually reexpanded. The diagnositic airleak indicator does require a small amount of fluid (e.g., 15 mL of fluid). This indicator is important for monitoring the function of the waterless system.

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Lesson 3 Post Test 1. An RN and an NAP are caring for a group of patients. Which of the following would be an appropriate action? a) Delegate assisting the physician in chest tube insertion to the NAP so the RN can take report on a new admission. b) Delegate milking or stripping the chest tube to the NAP while the RN administers pain medication to the patient. c) Delegate to the NAP clamping the chest tube while ambulating the patient in the hall three times a day. d) Delegate to the NAP informing the nurse if there is a disconnection of the system, sudden bleeding, or a sudden cessation of bubbling. Correct answer: d Rationale: The NAP should be instructed to inform the nurse if there is a disconnection of the system, a change in the type and amount of drainage, sudden bleeding, or a sudden cessation of bubbling. Only a nurse may assist a physician with chest tube insertion because of the level of skill required. Milking or stripping chest tubes should be done only when there is a physician’s order and an organizational policy covering this practice. Though assisting with ambulation may be delegated, chest tubes are never routinely clamped when the patient is ambulating and/or being transported to another location. 2. During your assessment of your patient’s record, what items are “red flags” that should be brought to the attention of the physician prior to chest tube insertion? (Select all that apply.) a) The patient has had a stroke and is receiving anticoagulants. b) The patient has arthritis, which is being treated with aspirin. c) Regular antiplatelet agent use. d) Regular caffeine use. e) The patient is a smoker. f) Hemoglobin value of 10 g per dL. g) Consent form lacks a signature. Correct answer: a, b, c, f, g Rationale: Anticoagulation therapy such as aspirin, warfarin, or heparin or platelet aggregation inhibitors (e.g., ticlopidine) can increase procedure-related blood loss. A low hemoglobin value is significant, because it indicates that the patient has a lower oxygen-carrying capacity. Further bleeding could negatively affect the patient. The physician should be notified if a signed consent form is missing. Since this procedure cannot be performed without a complete signed consent form because of the risks involved. It is unnecessary to notify the physician if the patient is a smoker or uses caffeine regularly, because these factors have little impact on this procedure. 3. What clinical signs and symptoms do you expect in a patient who requires chest tube insertion for a pneumothorax? (Select all that apply.) a) Shallow respirations at a rate greater than 20 breaths per minute b) Anxious and restless c) Diaphoretic Copyright © 2018, Elsevier Inc. All rights reserved.

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d) Cyanotic e) Chest pain f) Normal depth of breathing at a rate less than 20 breaths per minute g) Pulse oximetry reading greater than 95% Correct answer: a, b, c, d, e Rationale: Shallow, rapid respirations would be expected for the patient requiring a chest tube. The patient who is in need of a chest tube is usually in respiratory distress and has abnormal respiration rate and depth. If the patient is anxious and restless and possibly cyanotic before chest tube insertion, this may indicate a lack of oxygen. A patient who is in respiratory distress is often sweating. Chest pain is associated with a pneumothorax, thereby indicating that the patient needs a chest tube. 4. A patient with a hemothorax has a posterior chest tube located laterally in the fifth intercostal space connected to a water-seal drainage system. Pre-procedure vital signs were: temperature 99.0° F, pulse 104, respiration 26, and shallow blood pressure 144 over 92, and oxygen saturation 90%. You are evaluating the patient’s outcome. The physician should be notified of which of the following findings? (Select all that apply.) a) Temperature 99.0° F, pulse 80, respiration 20, blood pressure 130 over 80, pulse oximetry 93% b) Drainage changing to serous color c) Temperature 98.0° F, pulse 124, respiration 28, blood pressure 100 over 50, pulse oximetry 85% d) Bubbling in water-seal chamber immediately after chest tube insertion e) Bright-red drainage 8 hours after insertion f) 500 mL of drainage in 24 hours g) Asymmetrical chest movement Correct answer: c, e, g Rationale: After the procedure, the patient’s vital signs should move toward normal. You should notify the physician if the patient’s blood pressure drops and the pulse increases significantly, as this may be an indication of bleeding. If the patient’s respirations increase and the patient has more difficulty breathing, increased chest pain, decreased oxygen saturation, asymmetrical chest movement, or mediastinal shifting, then you should notify the physician, because this indicates either a worsening of condition or development of a tension pneumothorax. The patient’s drainage should change from a bloody appearance to a more serous color. The amount of drainage may be 500 to 1000 mL in the first 24 hours. You should report bright-red drainage since this indicates active bleeding. When you initially connect the system to the patient, bubbles are expected from the water-seal chamber. These are from air that was present in the system and in the patient’s intrapleural space. After a short time, this bubbling stops, and tidaling is noted. 5. A nursing student is helping care for a patient with a chest tube. The nursing student asks you ( the staff nurse) what determines the level of suction in the chest tube. What is your correct response? (Select all that apply.) a) “The depth of fluid in the suction control chamber of a water-seal system determines the highest amount of negative pressure that can be present within the system.” Copyright © 2018, Elsevier Inc. All rights reserved.

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b) “The setting of the wall suction determines the amount of negative pressure present within the water-seal system.” c) “The suction float ball indicates the amount of suction the patient’s intrapleural space is receiving in a waterless system.” d) “Whether it is a two-chamber or three-chamber system determines the level of suction. Three-chamber systems have more area to collect drainage, creating a greater negative intrapleural pressure.” Correct answer: a, c Rationale: In a water-seal system, the depth of fluid dictates the amount of negative pressure. For example, 20 cm of water is approximately 20 cm of water pressure. Any additional negative pressure applied to the system is vented into the atmosphere through the suction control vent. The setting of the wall suction is unrelated to the amount of negative pressure within the waterseal system. In a water-seal system, turning the wall suction up higher will only make the system noisier without increasing the amount of suction on the patient’s intrapleural space. In a waterless system, the suction float ball dictates the amount of suction in the system. The float ball allows only the level of suction dictated by its setting. The amount of drainage a drainage system can hold is unrelated to the level of suction in the chest tube. 6. Which postprocedure vital sign schedule meets the minimum needs of your patient? a) Every 15 minutes for the first 2 hours b) Every 10 minutes for the first hour c) Every 15 minutes for the first hour, then every 30 minutes for the next hour, and then every hour for the next 4 hours d) Every 15 minutes times 2, then every hour times 4, and then every 4 hours Correct answer: a Rationale: Every 15 minutes for the first 2 hours is a minimum and assumes that your patient’s vital signs remain stable and/or improve. 7. ...