A 45-year-old patient has undergone thoracic surgery and has a chest tube in place. The nurse observes continuous bubbling in the water seal chamber. What action should the nurse take?
A) Clamp the chest tube immediately
B) Increase the suction level
C) Document the finding as normal
D) Notify the healthcare provider
E) Remove the chest tube
Rationale:
Continuous bubbling in the water seal chamber indicates an air leak, which is abnormal. Notifying the healthcare provider is crucial to address this issue promptly and prevent complications such as pneumothorax. Clamping the chest tube or removing it without proper assessment can lead to serious respiratory complications.
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Understanding Chest Tubes: NCLEX Priority Questions
A patient with a chest tube drainage system reports sudden severe pain on the insertion side. What should the nurse do first?
A) Administer pain medication as ordered
B) Re-position the patient to the affected side
C) Check for kinks or obstructions in the tubing
D) Notify the healthcare provider
E) Remove the chest tube
Rationale:
Sudden severe pain on the insertion side may indicate a kink or obstruction in the chest tube system. The nurse should first assess for any potential issues in the tubing before administering pain medication or notifying the healthcare provider. Prompt intervention can prevent complications and ensure proper functioning of the chest tube.
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Understanding Chest Tubes: NCLEX Delegation Questions
A patient with a chest tube drainage system accidentally pulls the tube out. What is the nurse’s immediate action?
A) Cover the site with a sterile occlusive dressing
B) Assess the patient’s respiratory status
C) Re-insert the chest tube into the same site
D) Apply a non-occlusive dressing over the site
E) Document the incident in the chart
Rationale:
If a chest tube is accidentally dislodged, the nurse’s immediate action is to cover the site with a sterile occlusive dressing to prevent air from entering the pleural space. Assessing respiratory status is important, but covering the site takes precedence to maintain the integrity of the closed drainage system. Re-inserting the chest tube should only be done by the healthcare provider in a controlled environment.
Understanding Chest Tubes: Causes and Symptoms
A postoperative patient has a chest tube in place following lung surgery. The nurse notes that the drainage in the collection chamber has suddenly ceased. What is the most appropriate action for the nurse to take?
A) Increase the suction pressure
B) Milk the tubing gently to promote drainage
C) Assess for kinks or obstructions in the tubing
D) Remove the chest tube immediately
E) Document the finding as normal
Rationale:
Sudden cessation of drainage may indicate a kink or obstruction in the chest tube system. The nurse should first assess the tubing for any potential issues before taking any further action. Milking the tubing or increasing suction pressure without proper assessment can lead to complications. Prompt identification and resolution of kinks or obstructions help maintain effective chest drainage and prevent complications.
NCLEX Questions: Focus on Medications, Patients With Chest Tubes
A patient with a chest tube in place complains of increasing pain at the insertion site. The nurse assesses the patient and notes subcutaneous emphysema around the chest tube site. What is the nurse’s priority action?
A) Administer pain medication as ordered
B) Re-position the patient to the unaffected side
C) Notify the healthcare provider immediately
D) Apply a warm compress to the insertion site
E) Remove the chest tube
Rationale:
Subcutaneous emphysema around the chest tube site suggests air leakage into the tissues, which requires prompt attention. The nurse’s priority is to notify the healthcare provider immediately for further evaluation and intervention. Administering pain medication or re-positioning the patient may not address the underlying issue. Timely communication with the healthcare provider is crucial to prevent complications such as tension pneumothorax.
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NCLEX Focus Exploring Chest Tubes: Causes and Diagnosis
A patient with a chest tube drainage system accidentally pulls the tube out. The nurse observes respiratory distress in the patient. What is the nurse’s immediate action?
A) Re-insert the chest tube into the same site
B) Apply a sterile dressing over the site
C) Call a code blue and initiate CPR
D) Clamp the chest tube immediately
E) Administer oxygen via a non-rebreather mask
Rationale:
Accidental dislodgement of a chest tube can lead to respiratory distress. The nurse’s immediate action is to apply a sterile occlusive dressing over the site to prevent air from entering the pleural space. While re-inserting the chest tube may be necessary, it should be performed by the healthcare provider in a controlled setting. Initiating CPR or clamping the chest tube may exacerbate the situation. Providing oxygen via a non-rebreather mask can support oxygenation while awaiting further intervention.
NCLEX Review: Chest Tubes Treatments
A patient with a chest tube drainage system following a thoracic procedure reports sudden onset shortness of breath and chest pain. The nurse assesses the patient and notes diminished breath sounds on the affected side. What is the nurse’s immediate action?
A) Increase the suction level on the chest tube
B) Administer pain medication as ordered
C) Assess for kinks or obstructions in the tubing
D) Remove the chest tube immediately
E) Document the finding as normal
Rationale:
Diminished breath sounds on the affected side may indicate a kink or obstruction in the chest tube system leading to inadequate drainage. The nurse’s immediate action should be to assess the tubing for any potential issues before taking further action. Increasing suction or removing the chest tube without proper assessment can worsen the situation. Prompt identification and resolution of kinks or obstructions are essential to maintain effective chest drainage.
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NCLEX Questions Critical Thinking: Chest Tubes Symptoms
1000 Medical-Surgical Questions
A patient with a chest tube in place experiences sudden bubbling in the water seal chamber. The nurse notes that the bubbling is continuous. What is the nurse’s priority action?
A) Clamp the chest tube immediately
B) Increase the suction level on the chest tube
C) Document the finding as normal
D) Notify the healthcare provider
E) Remove the chest tube
Rationale:
Continuous bubbling in the water seal chamber indicates an air leak, which is abnormal. The nurse’s priority is to notify the healthcare provider immediately to address this issue promptly. Clamping the chest tube or removing it without proper assessment can lead to serious respiratory complications. Timely communication with the healthcare provider is crucial to prevent further complications.
A patient accidentally pulls out the chest tube while turning in bed. The nurse observes a sudden increase in respiratory distress. What is the nurse’s immediate action?
A) Re-insert the chest tube into the same site
B) Apply a sterile dressing over the site
C) Call a code blue and initiate CPR
D) Clamp the chest tube immediately
E) Administer oxygen via a non-rebreather mask
Rationale:
Accidental dislodgement of a chest tube can lead to respiratory distress. The nurse’s immediate action is to apply a sterile occlusive dressing over the site to prevent air from entering the pleural space. While re-inserting the chest tube may be necessary, it should be performed by the healthcare provider. Initiating CPR or clamping the chest tube may exacerbate the situation. Providing oxygen via a non-rebreather mask can support oxygenation while awaiting further intervention.
A postoperative patient with a chest tube drainage system complains of severe pain at the insertion site. The nurse notes that the pain is worsening, and the patient is restless. What is the nurse’s priority action?
A) Administer pain medication as ordered
B) Re-position the patient to the unaffected side
C) Notify the healthcare provider immediately
D) Apply a warm compress to the insertion site
E) Remove the chest tube
Rationale:
Severe pain at the chest tube insertion site, accompanied by restlessness, may indicate a complication such as tension pneumothorax. The nurse’s priority is to notify the healthcare provider immediately for further evaluation and intervention. Administering pain medication or re-positioning the patient may not address the underlying issue. Timely communication with the healthcare provider is crucial to prevent complications and ensure patient safety.