A nurse cares for a patient who had a chest tube placed six hours ago and refuses to take deep breaths because of the pain. What action should the nurse take?

Encourage the patient to take shallow breaths to help with the pain.

Auscultate the patient's anterior and posterior lung field

Ambulate the patient in the hallway to promote deep breathin

Administer pain medication and encourage the patient to take deep breaths.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Encouraging shallow breaths is contraindicated as it can lead to atelectasis and subsequent pneumonia. Deep breathing and coughing are vital post-chest tube insertion to re-expand the lung and clear secretions. Shallow breathing diminishes the ventilatory effort, increasing the risk for retained secretions and alveolar collapse, which can impair gas exchange and oxygenation, exacerbating the patient's condition and potentially prolonging recovery.

Choice B rationale

While auscultating lung fields is a standard assessment, it does not directly address the patient's pain-related refusal to perform deep breathing. The immediate priority is to manage the pain that is inhibiting a crucial therapeutic activity, which is deep breathing. Assessing lung sounds without first addressing the pain does not solve the root problem that is preventing the patient from participating in their care, thus delaying essential lung expansion and recovery.

Choice C rationale

Ambulation is a beneficial intervention for promoting lung expansion and preventing complications, however, it should not be the first action. Without adequate pain control, the patient will be unable to ambulate effectively or take deep breaths during the activity. Administering pain medication first makes ambulation more tolerable and effective by addressing the primary barrier to the patient's participation in therapeutic activities, ensuring the intervention is successful.

Choice D rationale

Pain is the primary reason the patient is refusing to take deep breaths. Administering pain medication addresses the underlying cause of the patient's reluctance. Once the pain is managed, the nurse can effectively encourage the patient to perform deep breathing exercises, which are essential for re-expanding the collapsed lung, clearing secretions, and preventing complications such as atelectasis and pneumonia, thereby facilitating a more rapid and successful recovery

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Correct Answer is ["A","B","E"]

Explanation

Paradoxical chest movement is the hallmark sign of flail chest. This occurs when two or more adjacent ribs are fractured in two or more places, creating a free-floating segment of the chest wall. During inspiration, the negative intrathoracic pressure causes the unstable segment to be pulled inward, while the rest of the chest expands. During expiration, the segment bulges outward, opposite the normal movement of the chest wall.

Choice B rationale

Flail chest involves significant trauma to the chest wall, including multiple rib fractures. This causes severe pleuritic pain, which is exacerbated by the movement of the chest wall during inspiration. The fractured ribs and associated soft tissue injury irritate the parietal pleura, leading to a sharp, stabbing pain that the patient describes as being worse with deep breaths.

Choice C rationale

Bradycardia is not a typical finding in flail chest. The patient's pain, respiratory distress, and potential hypoxemia trigger a sympathetic nervous system response. This compensatory mechanism leads to an increase in heart rate to maintain cardiac output and oxygen delivery to the tissues. Therefore, tachycardia is a more expected finding in a patient with flail chest. Normal heart rate is 60 to 100 beats per minute.

Choice D rationale

Jaundice, characterized by yellowing of the skin and eyes, is a result of hyperbilirubinemia, a condition associated with liver dysfunction, biliary obstruction, or excessive red blood cell destruction. It is not a direct finding or complication of flail chest, which is a musculoskeletal and respiratory injury. Jaundice would be a coincidental finding and not a direct sign.

Choice E rationale

Chest pain is a prominent and expected finding in a patient with flail chest. The pain is a direct result of the trauma, including multiple rib fractures and the associated soft tissue and muscle injury. The severity of the pain is often directly related to the number and location of the fractures and is a major contributor to the patient's respiratory distress. .

A. Continuous bubbling in the water-seal chamber. B. Bloody drainage in the collection chamber. C. Constant bubbling in the suction-control chamber. D. Fluid-level fluctuations in the water-seal chamber.

Correct Answer is A

Explanation

Choice A rationale

Continuous bubbling in the water-seal chamber indicates a persistent air leak within the chest tube system. This is an abnormal finding as bubbling should only occur intermittently during expiration or coughing. A continuous air leak prevents the establishment of a negative intrapleural pressure, compromising the lung's ability to re-expand and can indicate a loose connection or a pleural tear.

Choice B rationale

Bloody drainage in the collection chamber is expected following chest surgery, especially in the immediate postoperative period. The amount and rate of drainage are the key assessments. The drainage should decrease over time.

Choice C rationale

Constant bubbling in the suction-control chamber is the expected and desired finding when suction is applied. This continuous bubbling confirms that the prescribed level of suction is being delivered to the pleural space, which is essential for removing air and fluid and promoting lung re-expansion.

Choice D rationale

Fluid-level fluctuations, also known as tidaling, in the water-seal chamber are a normal and expected finding. This movement reflects the changes in intrapleural pressure during respiration. The fluid level rises with inspiration and falls with expiration, indicating that the chest tube is patent and the lung is not fully re-expanded

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A nurse cares for a patient who had a chest tube placed six hours ago and refuses to take deep breaths because of the pain. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is assessing a patient who has a suspected flail chest. Which of the following findings does the nurse recognize as common with flail chest?

Correct Answer is ["A","B","E"]

Explanation

The nurse is caring for a patient who is 12 hours postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations?

Correct Answer is A

Explanation

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