The provider writes an order for a client to have a chest tube removed. Which of the following are appropriate reasons to discontinue a chest tube? Select all that apply.
Breath sounds diminished on auscultation.
Improved respiratory status.
Symmetrical rise and fall of the chest.
Oxygen saturation at least 90%.
Continuous bubbling in water seal chamber.
Chest is asymmetrical on inspiration and expiration.
Bilateral breath sounds clear on auscultation.
Correct Answer : B,C,G
Choice A Reason:
Breath sounds diminished on auscultation indicate that there may still be fluid or air in the pleural space, suggesting that the chest tube is still needed to drain the pleural cavity. This is not an appropriate reason to discontinue a chest tube as it indicates ongoing issues that need to be resolved.
Choice B Reason:
Improved respiratory status is a key indicator that the chest tube has successfully resolved the underlying issue, such as a pneumothorax or pleural effusion. When the patient shows signs of stable and improved breathing, it suggests that the chest tube has served its purpose and can be safely removed.
Choice C Reason:
Symmetrical rise and fall of the chest during respiration indicate that both lungs are expanding and contracting normally. This symmetry is a sign that the pleural space is no longer compromised, making it an appropriate reason to remove the chest tube.
Choice D Reason:
Oxygen saturation at least 90% is a general indicator of adequate oxygenation but does not specifically address the condition of the pleural space. While important, it is not a direct reason to discontinue a chest tube without other supporting signs.
Choice E Reason:
Continuous bubbling in the water seal chamber indicates an ongoing air leak, which means that the chest tube is still necessary to evacuate air from the pleural space. This is not an appropriate reason to remove the chest tube.
Choice F Reason:
An asymmetrical chest on inspiration and expiration suggests that there is still an issue with lung expansion, possibly due to fluid or air in the pleural space. This condition requires the chest tube to remain in place until resolved.
Choice G Reason:
Bilateral breath sounds clear on auscultation indicate that both lungs are free of fluid and air, and are functioning normally. This is a strong indicator that the chest tube has achieved its purpose and can be safely removed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A: Observe for clear drainage.
Reason: Observing for clear drainage is important as it can indicate cerebrospinal fluid (CSF) leakage, especially after nasal or sinus surgery. CSF leakage is a serious complication that requires immediate medical attention. Clear drainage from the nose should be tested for the presence of glucose, which can confirm if it is CSF.
Choice B: Assess for signs of bleeding.
Reason: Assessing for signs of bleeding is crucial in the immediate postoperative period. Nasal packing can sometimes mask ongoing bleeding, so it is important to monitor for any signs of excessive blood loss. This includes checking for blood-soaked dressings, frequent swallowing (which can indicate blood trickling down the throat), and changes in vital signs such as increased heart rate and decreased blood pressure.
Choice C: Watch the client for frequent swallowing.
Reason: Watching the client for frequent swallowing is important because it can be a sign of posterior nasal bleeding. Blood can trickle down the back of the throat, causing the client to swallow frequently. This is a subtle but significant sign that should prompt further investigation and possible intervention.
Choice D: Change the nasal packing.
Reason: This choice is incorrect. Nasal packing should not be changed by the nurse without specific orders from the physician. Changing the packing prematurely can disrupt the surgical site, cause bleeding, and increase the risk of infection. The packing is usually removed by the surgeon or under their direct supervision.
Choice E: Administer a nasal steroid to decrease edema.
Reason: Administering a nasal steroid can help reduce inflammation and edema in the nasal passages. However, this should only be done if prescribed by the physician. Nasal steroids can help improve breathing and reduce discomfort, but they must be used according to medical guidance to avoid potential side effects.
Correct Answer is ["A","B","C"]
Explanation
Choice A reason: A 22-year-old client with asthma is considered a priority for pneumonia vaccination. Asthma is a chronic respiratory condition that can increase the risk of complications from pneumonia. Vaccination helps protect against pneumococcal infections, which can be particularly severe in individuals with underlying respiratory conditions.
Choice B reason: A healthy 72-year-old client is also a priority for pneumonia vaccination. The Centers for Disease Control and Prevention (CDC) recommends pneumococcal vaccination for all adults aged 65 years and older. Older adults are at higher risk for pneumococcal disease due to age-related decline in immune function.
Choice C reason: A client with well-controlled diabetes should be prioritized for pneumonia vaccination. Diabetes can weaken the immune system, making individuals more susceptible to infections, including pneumonia. Vaccination is an important preventive measure for individuals with chronic health conditions.
Choice D reason: A client who is taking medication for hypertension is not necessarily a priority for pneumonia vaccination based solely on their hypertension. While hypertension is a common condition, it does not directly increase the risk of pneumococcal disease. However, if the client has other risk factors or comorbidities, they may still be considered for vaccination.
Choice E reason: A client who had a cholecystectomy last year is not a priority for pneumonia vaccination based on this surgical history alone. A cholecystectomy, which is the removal of the gallbladder, does not increase the risk of pneumococcal disease. Priority for vaccination is typically given to individuals with chronic health conditions, older adults, and those with weakened immune systems.
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