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?
Crepitus in the area above and surrounding the insertion site
Bubbling of the water in the water seal chamber with exhalation
Eyelets are not visible
Movement of the trachea toward the unaffected side
The Correct Answer is D
Choice A Reason: This is incorrect because crepitus in the area above and surrounding the insertion site is not a serious finding that requires notification of the provider. Crepitus is a crackling sensation that occurs when air leaks into the subcutaneous tissue. It is usually harmless and resolves on its own.
Choice B reason: This is incorrect because bubbling of the water in the water seal chamber with exhalation is a normal finding that indicates that air is being removed from the pleural space. Bubbling should stop when the pneumothorax is resolved.
Choice C Reason: This is incorrect because eyelets are not visible is not a serious finding that requires notification of the provider. Eyelets are small holes at the end of the chest tube that allow air and fluid to drain from the pleural space. They are usually covered by a dressing and may not be visible.
Choice D Reason: This is correct because movement of the trachea toward the unaffected side is a serious finding that indicates a tension pneumothorax, which is a life-threatening condition that occurs when air accumulates in the pleural space and causes pressure on the mediastinum. The nurse should notify the provider immediately and prepare for needle decompression or chest tube insertion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because a pneumothorax is a condition in which air enters the pleural space and causes the lung to collapse. It does not cause the chest wall to move inward and outward paradoxically.
Choice B Reason: This is incorrect because atelectasis is a condition in which alveoli collapse and cause reduced gas exchange. It does not cause the chest wall to move inward and outward paradoxically.
Choice C Reason: This is correct because flail chest is a condition in which multiple ribs are fractured and cause a segment of the chest wall to detach from the rest of the thoracic cage. It causes the chest wall to move inward and outward paradoxically, as well as dyspnea and pain.
Choice D Reason: This is incorrect because a hemothorax is a condition in which blood enters the pleural space and causes the lung to collapse. It does not cause the chest wall to move inward and outward paradoxically.
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because clamping the client's chest tube can cause a tension pneumothorax, which is a life-threatening condition that requires immediate intervention.
Choice B Reason: This is incorrect because increasing the client's wall suction can cause excessive negative pressure in the pleural space, which can damage the lung tissue and impair ventilation.
Choice C Reason: This is correct because repositioning the client can help relieve chest burning, which may be caused by irritation of the intercostal nerves by the chest tube or by air trapping in the pleural space.
Choice D Reason: This is incorrect because stripping the client's chest tube can create high negative pressure in the pleural space, which can damage the lung tissue and impair ventilation.
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