A nurse is assessing a client who has a pneumothorax with a chest tube in place.
For which of the following findings should the nurse notify the provider?
Movement of the trachea toward the unaffected side.
Eyelets are not visible.
Crepitus in the area above and surrounding the insertion site.
Bubbling of the water in the water seal chamber with exhalation.
The Correct Answer is A
Chest tube management for pneumothorax involves monitoring for clinical complications and system patency. This scenario requires applying knowledge of respiratory emergencies, specifically recognizing signs of tension pneumothorax, which is a life threatening complication characterized by shifting of thoracic structures.
Choice A rationale
Tracheal deviation toward the unaffected side signifies a tension pneumothorax. This occurs when intrapleural pressure increases significantly, causing a mediastinal shift that compresses the heart and opposite lung, requiring immediate needle decompression or chest tube adjustment by providers.
Choice B rationale
Eyelets are the drainage holes at the end of the chest tube. If they are not visible, it indicates the tube is correctly positioned within the pleural space. Visible eyelets would suggest the tube has partially dislodged.
Choice C rationale
Crepitus, or subcutaneous emphysema, is a common finding where air leaks into subcutaneous tissues around the insertion site. While it should be monitored and documented, it generally does not require emergency provider notification unless it rapidly expands.
Choice D rationale
Intermittent bubbling in the water seal chamber during exhalation or coughing is expected in a patient with a pneumothorax. It indicates that air is successfully being evacuated from the pleural space into the drainage system.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["13376"]
Explanation
This scenario requires calculating fluid resuscitation requirements for a burn patient. Knowledge of the Parkland formula is necessary to determine the total volume of isotonic crystalloids required based on weight and the percentage of total body surface area burned.
Step 1 is 4 mL × 88 kg × 38 percent.
Step 2 is 352 × 38.
Step 3 is 13376 mL.
Correct Answer is {"A":{"answers":"A,C"},"B":{"answers":"A,C"},"C":{"answers":"B"},"D":{"answers":"A,C"},"E":{"answers":"A,C"},"F":{"answers":"A,B,C"},"G":{"answers":"A,C"}}
Explanation
- Pulmonary Embolism (PE): This is a high-priority concern following a total hip arthroplasty. The sharp chest pain (pleuritic), restlessness, anxiety, tachycardia (104 bpm), and low SpO2 (90%) are classic indicators of a PE, which is often caused by a clot traveling from the surgical site or lower extremities.
- GERD: The client’s report of belching (eructation) after eating "onions and peppers" and the location of the chest pain (which can mimic indigestion) are consistent with gastroesophageal reflux. However, GERD would not explain the tachycardia or hypoxia.
- Respiratory Infection: Findings such as dyspnea, hypoxia, tachycardia, and restlessness can be seen in infections like pneumonia, especially in post-operative clients who may have atelectasis. The "sharp pain on deep breath" can also indicate pleurisy associated with infection.
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