A client who had thoracic surgery is admitted to the
postanesthesia care unit. The nurse notes that a chest tube is in
place and is attached to a disposable plastic, water-seal drainage
system. To provide appropriate care of the chest tube and
drainage unit, which step would the nurse take next?
1. Ensure the security of the connections from the client to the
drainage unit.
2. Empty the drainage container and measure and record the
amount.
3. Verify that there is vigorous bubbling in the wet suction
control compartment.
4. Check that the fluid level in the water-seal compartment
increases with expiration. Correct Answers 1. Ensure the security
...... ......
of the connections from the client to the drainage unit.
Which finding best indicates that the chest tube for a client with
a pneumothorax may be discontinued?
1. Clear breath sounds heard in both lungs
2. Oxygen saturation reading is higher than 90%
3. Absence of bubbling in the water-seal chamber
4. Full re-expansion of the lungs seen on chest x-ray Correct
......
Answers 4. Full re-expansion of the lungs seen on chest x-ray
.... ..
When a client who has a chest tube after thoracotomy reports
sharp chest pain at the chest tube and refuses to take deep
breaths, which action by the nurse is best?
1. Assist the client to sit up in a chair.
2. Administer prescribed pain medications.
3. Educate about the reason for deep breathing.
,4. Explain that some pain is normal with a chest tube. Correct ......
Answers 2. Administer prescribed pain medications.
.... ..
Which finding in a client who has had a chest tube removed
would be of most concern to the nurse?
1. Poor cough effort
2. Pain at chest tube site
3. Crepitus at the chest tube site
4. Two centimeters of pink drainage on dressing Correct ......
Answers 3. Crepitus at the chest tube site
.... ..
A nurse is caring for a client with a pneumothorax who has a
chest tube attached to a closed chest drainage system. If the
chest tube and closed chest drainage system are effective, which
type of pressure will be reestablished?
1. Neutral pressure in the pleural space
2. Negative pressure in the pleural space
3. Atmospheric pressure in the thoracic cavity
4. Intrapulmonic pressure in the thoracic cavity Correct Answers
......
2. Negative pressure in the pleural space
......
Which action would the nurse take to determine patency of the
chest tube and closed chest drainage system in a client after left
lower lobectomy?
1. Milk the chest tube toward the drainage unit.
2. Check the amount of bubbling in the suction control chamber.
3. Observe for fluctuations of the fluid in the water-seal
chamber.
4. Assess for extent of chest expansion in relation to breath
sounds. Correct Answers 3. Observe for fluctuations of the fluid
...... .... ..
in the water-seal chamber.
, Which information would be used to determine the cause of
premature atrial contractions (PACs) observed on a client's
EKG? Select all that apply. One, some, or all responses may be
correct.
1. Stress level
2. Tobacco use
3. Caffeine intake
4. Electrolyte levels
5. Home medications Correct Answers 1. Stress level
...... ......
2. Tobacco use
3. Caffeine intake
4. Electrolyte levels
5. Home medications
Which action is essential for the nurse to include in the plan of
care for a client with atrial fibrillation?
1. Take pulse apically for a full minute.
2. Monitor blood pressure at least every 2 hours.
3. Ask client to call for assistance when ambulating.
4. Teach client to avoid taking over-the-counter aspirin. Correct
......
Answers 1. Take pulse apically for a full minute.
.... ..
When teaching a client with atrial fibrillation about a new
prescription for warfarin, the nurse will include information
about which vitamin?
1. Vitamin K
2. Vitamin D
3. Vitamin B1
4. Vitamin B12 Correct Answers 1. Vitamin K
...... ... ...
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