ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 21 : Caring for Clients With Lower Respiratory Disorders Questions
Question 1 of 5
A client is admitted to the emergency department with a stab wound and is now presenting dyspnea, tachypnea, and sucking noise heard on inspiration and expiration. The nurse should care for the wound in which manner?
Correct Answer: C
Rationale: The client has developed a pneumothorax, and the best action is to prevent further deflation of the affected lung by placing an airtight dressing over the wound. A vented dressing would be used in a tension pneumothorax, but because air is heard moving in and out, a tension pneumothorax is not indicated. Applying direct pressure is required if active bleeding is noted.
Question 2 of 5
The client asks the nurse to explain the reason for a chest tube insertion in treating a pneumothorax. Which is the best response by the nurse?
Correct Answer: D
Rationale: Negative pressure must be maintained in the pleural cavity for the lungs to be inflated. An injury that allows air into the pleural space will result in a collapse of the lung. The chest tube can be used to drain fluid and blood from the pleural cavity and to instill medication, such as talc, to the cavity.
Question 3 of 5
The nurse is caring for a client with tension pneumothorax. Which nursing assessment would alert the nurse to the development of a mediastinal shift in this client?
Correct Answer: D
Rationale: In a tension pneumothorax, the air is sucked into the pleural cavity and cannot escape. The air accumulates and pushes the trachea, esophagus, heart, and great vessels toward the unaffected side. Fluctuation of the fluid in the water-seal chamber is an expected finding. There may be a paradoxical movement of the ribs but not a shifting to the side. A sucking sound may be heard with a pneumothorax, but air moves in and cannot escape out.
Question 4 of 5
When the nurse monitors the water-sealed drainage system, which finding suggests the system is working properly?
Correct Answer: A
Rationale: Fluctuation of fluid in the water-sealed chamber is initially present with each respiration. The level of fluid in the suction chamber should be maintained to initial level. Excessive or vigorous bubbling can indicate a leak in the system. The fluid in the chamber is clear.
Question 5 of 5
The nurse is caring for a client with a chest tube. Which nursing assessment would alert the nurse to a possible complication?
Correct Answer: D
Rationale: Subcutaneous emphysema is the result of air leaking between the subcutaneous layers. It is not a serious complication but is notable and reportable. Pink skin and blood in the collection chamber are normal findings. When two tubes are inserted, the posterior or lower tube drains fluid, whereas the anterior or upper tube is for air removal.