ATI Skills - Closed Chest Drainage Post Test

Skills Module 3.0: Closed-Chest Drainage Posttest Question: 1 of 8 CORRECT А nurse is caring for а client who is б hr postoperative and has а chest tube in place that is attached to а closed­ chest water-seal drainage system. The nurse should identify that which of the following is an indication of а proЫem in the drainage system? • • • • о о о • • • • • • • о Constant bubЬling in the suctюn-control chamber INCORRECT The nurse should expect constant, gentle bubЫing in the suction-control chamber. Vigorous bubЬling in this chamber сап disturb the client, and it also increases the rare of warer evaporation while decreasing the amounr of suction. Fluctuations 1n the fluid level in the water-seal chamber INCORRECT The nurse should expect to see flucruation in the fluid level in the water-seal chamber with inspiration and exhalation, as this reflects the expected pressure changes in the pleural space during respiration. Fluctuation stops when the lung has re­ expanded, but it can also stop when the tuЫng is obstructed, а dependent loop hangs below the rest of the tuЫng, ог the suction source is not funcrtoning. Occasional bubЬling 1n the water-seal chamber INCORRECT The nurse should expect occasional bubЬling in rhe water seal chamber, especially when the client coughs ог exhales forcefully. The bubЬles indicate the removal of air from the pleural space, which is the expected result. Continuous bubЬling in the water-seal chamber CORRECT Excessive and continuous bubЬling in the water-seal chamber indicates an air leak in the drainage system. The nurse should use rubber-tipped clamps to try to locate the leak Ьу clamping the tube momentarily near the site of the chest cube insenion. Skills Module 3.0: Closed-Chest Drainage Posttest Question: 2 of 8 CORRECT А nurse is caring for а client who has а chest tube in place. Which ofthe following strategies should the nurse use to help promote comfort for the client? • • • • о о о • • • • • • • • • • о Have the client splint the affected side during cough1ng. CORRECT lt is essential for а client with а chest tube to cough to prevent postoperative complications and to help drain the pleural space and expand the lungs. Splinting the affected side, such as with а pillow, can help minimize the pain of coughing. The nurse should also administer analgesia to help reduce the pain of coughing and other activities. � Perform passive range-of-morion exercises. INCORRECT Although passive range-of-motion exercises on the affected side can help prevent postoperative complications related to immobllity and preserve joint function, they can Ье painful for а client who has а chest tube. The nurse should administer analgesia 30 min prior to passive range-of-motion exercises to promote comfort for the client. Place the client in а supine position with m1n1mal elevat1on. INCORRECT The client should Ье placed in an upright position to allow optimal lung expansion. The nurse should elevate the head of the client's bed to at least 30 ° . Encourage ambulatюn. INCORRECT Although ambulation сап help prevent postoperative complications and help the client feel that the recovery is progressing, it сап Ье painful with а chest tube in place. The nurse should administer analgesia 30 min prior to ambulation to promote comfort for the client. 1/2 Skllls Module з.о: Closed-Chest Drainage Posttest Question: З of 8 CORRECТ А nurse is preparing to transport а client who has а chest tube and а closed-chest wet-suction drainage system to radiology. Which of the fo\lowing actions shou\d the nurse take when detaching the suction source for transportation? • • • • • • • • о Clamp the chest tube, INCORRECT The nurse should never clamp а chest tube during transportation, as it increases the risk fo r tension pneumothorax. Milk rhe chest rube. INCORRECT The nurse should not milk tuЫng because this increases the pressure in the intrathoracic cavity and сап damage lung tissue. Make sure the air vent is open. CORRECT Some closed-chest dralnage systems and suctlon devlces contain а vent from the water-seal chamber. Thls allows the drainage unit to remain vented withour suction. So, the nurse should make sure this exit vent is open when disconnecting the suction source. Е, ,pty the collectюn chamber. INCORRECT Closed-chest wet-suction drainage sysrems are dlsposaЫe. When the colleaion chamber ls nearly full, the nurse should replace lt, rather than empty it. 1/2 Skills Module 3.0: Closed-Chest Drainage Posttest Question: 4 of 8 CORRECT А nurse is caring for а client who has а chest tube in place that is attached to а water-seal drainage system. Which of the following findings should the nurse recognize as an indication of subcutaneous emphysema? • • • • о о о • • • • • • • • • • о DIm I n1shed lung sounds on the affected sIde INCORRECT Diminished lung sounds оп the affected side is an indication that the lung has not yet ful ly re-expanded. This is not а finding associated with subcutaneous emphysema. А dry, с, ackling sound at the insertion site when palpated CORRECT А dry, crackiing sound at the inse11ion site is an indication of subcutaneous emphysema, which is а result of air leaking into the subcutaneous tissue surrounding the chest-tube inse11ion site. АЬsепсе of dra1nage In the coilection chamber INCORRECT Absence of drainage in the collection chamber is ап indication of ап obstruction in the chest tube or the drainage system·s tublng. This is not а finding associated with subcutaneous emphysema. Hyperresonance when percussing the affected lung INCORRECT Hyperresonance over the affected lung could Ье an indication of tension pneumothorax. This finding requires immediate acrion Ьу the nurse. However, this is not а finding associated with subcutaneous emphysema. 1/2 Skil\s Module З.О: Closed-Chest Dralnage Posttest Question: 5 of 8 CORRECT А nurse is caring for а client who has а chest tube in place that is attached to а closed-chest drainage system. Which of the following actions should the nurse take if the chest tube becomes dislodged from the closed-chest drainage system? • • • • о о о • • • • • • • • • • о lnstruct the client to 1nhale deeply. INCORRECT The client should Ье instr ucted to exhale. not inhale. Exhaling assists with removing as much air as possiЫe from the pleural space, whereas inhaling increases the amount of air and could create а pneumothorax. Submerge the end of the chest tube n 1 1nch of sterile water. CORRECT This action creates а water seal and prevents air from entering the pleural space through the open end of the chest tube when the client inhales. Gently mIlk the chest tube In а proxImal-to-d1stal d1rectIon. INCORRECT Milking the rube involves intermittently compressing it in the area of the clot for 1 to 2 seconds. Тhis action could increase negative pressure within the system to а level that сап damage the pleural tissue. Таре sterile gauze around the open end of the chest tube. INCORRECT Taping sterile gauze around the end of the tube wlll stlll allow unwanted alr to Ье inhaled lnto the cllent·s pleural space. 19 1/2 Skills Module 3.0: Closed-Chest Drainage Posttest Question: б of 8 CORRECТ А nurse is caring for а client who requires а chest tube. The provider asks for the suction pressure of the closed­ chest drainage system to Ье set at -40 cm of water. Which of the following closedchest drainage systems should the nurse prepare for this client? • • • • о о о • • • • • • • • • • о Pneumostat "' INCORRECT Pneumostat� is а type of moЫle chest draln with а one-way valve that attaches directly to the chest-tube to collect fluid. This device is appropriate for а small or partial pneumothorax. lt cannot accommodate thls cllent's need for high sualon pressures. '--- Water-seal system INCORRECT А traditional closed-chest water-seal drainage system regulates the amount of suction Ьу the height of the water in the suction­ control chamber, typically applying а suction pressure of -20 cm ofwater to the pleural cavity. This type of system might not deliver the high suction pressures this client requires. He1mlich valve INCORRECT А heimlich valve is а type of moЫle chest drainwith а one-way flutter valve that allows air to escape but keeps it from re­ entering the chest cavity. This device is appropriate for а small or partia\ pneumothorax and does not collect fluid. lt cannot accommodate this client's need for high suction pressures. r.:,. Dry suction-control system CORRECT Systems that use dry-suction control allow for higher suction pressures Ьу adjusting а dial on the front surface of the system to deliver suction pressure up to -40 cm ofwater . Some clients need high suction pressures due to а massive air leak from the lung surface, emphysema or viscous pleural effusion, or а reduction in pulmonary compliance. 1/2 Skills Module 3.0: Closed-Chest Drainage Posttest Question: 7 of 8 CORRECT А nurse 1s assesslng а cllent 5 hr after the insertion of а chest tube that is attached to а water-seal drainage system. Which of the following observations about the drainage should the nurse report to the provider? • • • • о о о • • • • • • • • • • о 400 mL dra1nage since 1nsertion INCORRECT The nurse should expect drainage of 100 to 300 mL of fluid during the first 3 hr after pleural insertion of а chest tube. Because the chest tube was inserted 5 hr ago, 400 ml of drainage Is wlthln the expected reference range. r А gush of fluid when repositioning the client INCORRECT А sudden gush of drainage when repositioning а client is often due to retained Ыооd, rather than active Ыeeding. Unless the total amount exceeds the expected range of drainage for this client at thls time, the nurse does not need to report this to the provider. About 150 mUhr dra1nage over the past 2 hr CORRECT After the first few hours, the nurse should report drainage that exceeds 70 mUhr. Clients who lose 100 ml of Ыооd every 15 min might require autotransfusion within 6 hr. ,,,--._ S1gnificant decrease In drainage over the past 3 hr INCORRECT The nurse should expect drainage of 100 to 300 mL of fluid during the first З hr after pleural chest-tube insertion. The amount of drainage begins to decrease around 2 hr after insertion, so this is an expeaed finding. 1/2 Skills Module 3.0: Closed-Chest Drainage Posttest Question: 8 of 8 CORRECT А nurse is planning education for а client who has а chest tube in place that is attached to а closed-chest drainage system. Which of the following instructions should the nurse plan to provide when the client is ready to ambulate? • • -.J • • о о о • • • • • • • • • • о Кеер the collection devIce upпght at all tImes. CORRECT The closed-chest drainage system must Ье kept upright at all times to ensure thatthe tublng drains optimally and the system functions correctly. ,,... DIsconnect the system when showering. INCORRECT The client must not disconnect the system at апу time. Disconnecting the system сап result in air entering the pleural space, which сап cause or worsen а pneumothorax. Кеер the collectюn devIce at chest level at all times. INCORRECT The nurse should instruct the client to keep the drainage system below the level of the chest when sitting or ambulating to ensure ргореr functioning and drainage. Allow the tubIng to hang ,n а dependent loop when ambulating. INCORRECT The client should avoid creating dependent loops of tublng. When the client cannot avoid them, the nurse should lift the tuЫng еvегу 1 5 min to allow its contents to drain. 112