The nurse is caring for a client with a pneumothorax who has a chest tube connected to a closed drainage system with suction. Which of the following actions should the nurse include in the plan of care?

Monitoring for the presence of bubbling in the suction chamber

Increasing the amount of suction if drainage decreases

Observing the amount of fluid in the drainage tubing

Preparing for removal of chest tube system after 24 hours

Answer and Explanation

The Correct Answer is C

A. Continuous bubbling in a suction chest tube can indicate an air leak. In a properly functioning wet suction system, intermittent bubbling is normal in the water seal chamber, but bubbling in the suction chamber itself is not always required. Monitoring for air leaks is important, but the presence of suction bubbling is not the primary focus for patient care monitoring.

B. Suction levels are prescribed by the healthcare provider and should not be increased based on decreased drainage. Drainage may decrease naturally as the pneumothorax resolves. Changing suction settings independently can cause lung trauma or excessive negative pressure.

C. Monitoring drainage amount and color is a primary nursing responsibility. It provides information about ongoing bleeding, air leaks, or resolution of the pneumothorax. Sudden increases or changes in drainage can indicate complications that require prompt intervention.

D. Chest tube removal is not time-dependent; it is based on clinical assessment, radiographic evidence of lung re-expansion, and absence of significant air leaks or drainage. Premature removal could lead to recurrence of the pneumothorax.

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Correct Answer is A

Explanation

A. A blunt injury occurs when the body is struck by a non-sharp objector force, causing tissue damage without breaking the skin. A baseball bat delivers direct force to the abdomen, potentially resulting in internal bleeding, organ contusions, or hematomas, which are characteristic of blunt trauma.

B. Thermal injuries are caused by heat, fire, or extreme cold, resulting in burns or frostbite, which is unrelated to trauma from a baseball bat.

C. Lacerations involve a tear or cut in the skin or underlying tissue, usually caused by a sharp object. In this scenario, the skin may remain intact despite internal injury, so a laceration is not the primary classification.

D. Penetrating injuries occur when a sharp object pierces the skin and enters body tissues, such as a knife or bullet. A baseball bat does not penetrate the skin, so this type does not apply.

A. Administer oxygen at 100% per non-rebreather mask B. Place the patient on continuous cardiac monitor C. Draw blood to type and crossmatch for transfusions D. Insert two 14-gauge IV catheters in antecubital space

Correct Answer is A

Explanation

A. Administer oxygen at 100% per non-rebreather maskis correct because the patient shows signs of hypovolemic shock(cool, clammy skin, tachycardia, hypotension), indicating inadequate tissue perfusion and oxygenation. The first priority in shock is always airway and oxygenationto prevent organ hypoxia and further deterioration. Oxygen administration is immediate and lifesaving.

B. Place the patient on continuous cardiac monitoris important but is secondary. Monitoring helps detect dysrhythmias caused by shock, but it does not directly correct hypoxiaor improve tissue perfusion, which are higher priorities.

C. Draw blood to type and crossmatch for transfusionsis necessary for fluid resuscitation, especially if hemorrhage is suspected, but it is not the first action. Ensuring oxygen delivery to tissues comes before preparing for transfusion.

D. Insert two 14-gauge IV catheters in antecubital spaceis also important for rapid fluid or blood administration, but it comes after oxygen therapy is initiated, since airway and oxygenation take precedence over vascular accessin the initial assessment.

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The nurse is caring for a client with a pneumothorax who has a chest tube connected to a closed drainage system with suction. Which of the following actions should the nurse include in the plan of care?

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