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"]
Explanation
Choice A Reason:
Suction equipment at the bedside.
Having suction equipment at the bedside is crucial for a client with status epilepticus. During a seizure, there is a risk of aspiration due to excessive salivation or vomiting. Suction equipment allows the nurse to quickly clear the airway, preventing aspiration and ensuring the client can breathe properly. This precaution is essential to maintain the client’s airway and prevent complications such as aspiration pneumonia.
Choice B Reason:
Continuous sedation.
Continuous sedation is not typically a standard precaution for all clients with status epilepticus. While sedation may be necessary in some cases to control seizures, it is not a universal precaution. The primary goal is to stop the seizure activity and stabilize the client. Continuous sedation may be used in specific situations under close medical supervision, but it is not a general precaution that nurses implement for all clients with status epilepticus.
Choice C Reason:
Side rails padded.
Padding the side rails of the bed is an important precaution to prevent injury during a seizure. Clients experiencing seizures may have uncontrolled movements, which can lead to injury if they hit the hard surfaces of the bed. Padded side rails help to cushion these impacts, reducing the risk of bruises, cuts, or fractures. This precaution is essential for ensuring the client’s safety during seizure activity.
Choice D Reason:
Bed in low position.
Keeping the bed in a low position is another important safety measure. If a client with status epilepticus were to fall out of bed during a seizure, the lower height reduces the risk of serious injury. This precaution helps to minimize the impact of any potential falls, ensuring the client’s safety. It is a simple yet effective measure to prevent harm during seizure episodes.
Choice E Reason:
Intravenous (IV) access.
Establishing intravenous (IV) access is critical for a client with status epilepticus. IV access allows for the rapid administration of medications needed to control seizures and manage the client’s condition. In an emergency, quick access to the bloodstream is essential for delivering life-saving treatments. This precaution ensures that the medical team can promptly and effectively intervene to stop the seizure activity.
Correct Answer is ["E","F","G"]
Explanation
Choice A reason:
Hypertension is not typically associated with myxedema coma. Myxedema coma is characterized by severe hypothyroidism, which usually leads to low blood pressure (hypotension) rather than high blood pressure (hypertension). Therefore, hypertension is not a clinical manifestation that indicates progression to myxedema coma.
Choice B reason:
Restlessness is not a common symptom of myxedema coma. Patients with myxedema coma often present with lethargy, confusion, or even coma due to the severe slowing of metabolic processes. Restlessness is more commonly associated with hyperthyroidism or other conditions that increase metabolic activity.
Choice C reason:
An increased level of alertness is contrary to the symptoms of myxedema coma. Myxedema coma typically presents with decreased mental status, including confusion, stupor, or coma. Therefore, an increased level of alertness would not be indicative of progression to myxedema coma.
Choice D reason:
Tachycardia (rapid heart rate) is not a typical symptom of myxedema coma. Instead, myxedema coma is associated with bradycardia (slow heart rate) due to the severe hypothyroid state. Tachycardia is more commonly seen in hyperthyroid conditions.
Choice E reason:
Hypotension (low blood pressure) is a key clinical manifestation of myxedema coma. The severe hypothyroid state leads to decreased cardiac output and vascular resistance, resulting in hypotension. This is a critical sign that the nurse should recognize as indicative of progression to myxedema coma.
Choice F reason:
Bradycardia (slow heart rate) is another hallmark of myxedema coma. The decreased metabolic rate in severe hypothyroidism leads to a reduced heart rate. Recognizing bradycardia is essential in identifying the progression to myxedema coma.
Choice G reason:
Hypoventilation (reduced breathing rate) is a significant symptom of myxedema coma. The severe hypothyroid state can lead to respiratory depression, resulting in hypoventilation. This can further exacerbate the patient’s condition and requires immediate medical attention.
Choice H reason:
Hyperventilation (increased breathing rate) is not associated with myxedema coma. Patients with myxedema coma typically experience hypoventilation due to the severe slowing of metabolic processes. Hyperventilation would be more indicative of conditions that increase metabolic activity or respiratory drive.
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