Question 1

What does the expected role of the nurse include during chest tube removal?

Accepted Answer

A) Prepares an occlusive dressing 
B) Performs clipping of the sutures 
C) Provides support and assessment of the patient 
D) Removes the chest tube firmly and quickly 
A) Prepares an occlusive dressing 
B) Performs clipping of the sutures 
C) Provides support and assessment of the patient 
D) Removes the chest tube firmly and quickly

Question 2

The nurse is caring for a patient with a chest tube connected to water-seal drainage.The nurse may delegate which of the following tasks to nursing assistive personnel (NAP)?

Accepted Answer

A) Changing the chest tube drainage system 
B) Milking the chest tube 
C) Measuring chest tube output 
D) Turning and positioning the patient 
A) Changing the chest tube drainage system 
B) Milking the chest tube 
C) Measuring chest tube output 
D) Turning and positioning the patient

Question 3

For a patient with a pneumothorax, where does the nurse anticipate that the chest tube will be located?

Accepted Answer

A) Second to third intercostal space (apical), anterior 
B) Fifth to sixth intercostal space, posterior 
C) Fifth to sixth intercostal space, lateral 
D) Mediastinal area 
A) Second to third intercostal space (apical), anterior 
B) Fifth to sixth intercostal space, posterior 
C) Fifth to sixth intercostal space, lateral 
D) Mediastinal area

Question 4

During assessment of a patient, the chest tube becomes dislodged.What should the nurse do first?

Accepted Answer

A) Have an assistant apply an occlusive gauze dressing and tape on all four sides. 
B) Clamp the chest tube. 
C) Attempt to gently reinsert the tube. 
D) Apply pressure over the insertion site. 
A) Have an assistant apply an occlusive gauze dressing and tape on all four sides. 
B) Clamp the chest tube. 
C) Attempt to gently reinsert the tube. 
D) Apply pressure over the insertion site.

Question 5

What is the expected amount of drainage for an adult patient with a posterior chest tube?

Accepted Answer

A) 100 to 300 mL during the first 3 hours 
B) 10 to 50 mL during the first 2 hours 
C) 200 mL during the first 24 hours 
D) 400 to 500 mL during the first 24 hours 
A) 100 to 300 mL during the first 3 hours 
B) 10 to 50 mL during the first 2 hours 
C) 200 mL during the first 24 hours 
D) 400 to 500 mL during the first 24 hours

Question 6

The nurse is caring for a patient with a chest tube that was inserted 4 days earlier.She notices that the drainage is blood-tinged.What might this indicate to the nurse? (Select all that apply.)

Accepted Answer

A) Malignancy 
B) Pulmonary infarction 
C) Empyema 
D) Hemothorax 
A) Malignancy 
B) Pulmonary infarction 
C) Empyema 
D) Hemothorax

Question 7

Which of the following is an expected outcome of chest tube insertion?

Accepted Answer

A) Mild chest pain is maintained. 
B) Breath sounds are auscultated in all lobes. 
C) Drainage from the pleural cavity increases over time. 
D) Lung expansion is increased beyond the unaffected side. 
A) Mild chest pain is maintained. 
B) Breath sounds are auscultated in all lobes. 
C) Drainage from the pleural cavity increases over time. 
D) Lung expansion is increased beyond the unaffected side.

Question 8

The nurse is caring for a patient who has a chest tube.Attached to the top of the patient's bed are two shodded hemostats.In which situations would these be used? (Select all that apply.)

Accepted Answer

A) To assess an air leak 
B) To quickly empty or change disposable systems 
C) To quickly seal off the lungs if the system becomes disconnected 
D) To assess whether the patient is ready to have the chest tube removed 
A) To assess an air leak 
B) To quickly empty or change disposable systems 
C) To quickly seal off the lungs if the system becomes disconnected 
D) To assess whether the patient is ready to have the chest tube removed

Question 9

Of the following nursing assessments, which should be reported to the primary care provider immediately by the nurse?

Accepted Answer

A) Bloody drainage from a patient with a hemothorax 
B) Subcutaneous emphysema is noted on assessment 
C) Bubbling in the water seal stops on a patient with a pneumothorax 
D) Over 300 mL of drainage has been collected in the system in the past hour 
A) Bloody drainage from a patient with a hemothorax 
B) Subcutaneous emphysema is noted on assessment 
C) Bubbling in the water seal stops on a patient with a pneumothorax 
D) Over 300 mL of drainage has been collected in the system in the past hour

Question 10

A pneumothorax can be caused by which of the following? (Select all that apply.)

Accepted Answer

A) Trauma 
B) Rupture of a blister 
C) Emphysema 
D) Dyspnea 
A) Trauma 
B) Rupture of a blister 
C) Emphysema 
D) Dyspnea

Exam 26: Closed Chest Drainage Systems

What does the expected role of the nurse include during chest tube removal?

The nurse is caring for a patient with a chest tube connected to water-seal drainage.The nurse may delegate which of the following tasks to nursing assistive personnel (NAP)?

For a patient with a pneumothorax, where does the nurse anticipate that the chest tube will be located?

During assessment of a patient, the chest tube becomes dislodged.What should the nurse do first?

What is the expected amount of drainage for an adult patient with a posterior chest tube?

The nurse is caring for a patient with a chest tube that was inserted 4 days earlier.She notices that the drainage is blood-tinged.What might this indicate to the nurse? (Select all that apply.)

Which of the following is an expected outcome of chest tube insertion?

The nurse is caring for a patient who has a chest tube.Attached to the top of the patient's bed are two shodded hemostats.In which situations would these be used? (Select all that apply.)

Of the following nursing assessments, which should be reported to the primary care provider immediately by the nurse?

A pneumothorax can be caused by which of the following? (Select all that apply.)

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