The nurse would check for leaks in the chest tube and water seal system when:

there is continuous bubbling in the water-seal chamber.

the water levels in the water-seal chamber and suction chambers are decreased.

fluid in the water-seal chamber fluctuates with the client's breathing.

there is constant bubbling in the suction-control chamber.

Answer and Explanation

The Correct Answer is A

A. There is continuous bubbling in the water-seal chamber: Continuous bubbling in the water-seal chamber suggests a potential air leak in the system, which needs to be investigated. The water-seal chamber is designed to prevent backflow of air into the pleural space, and persistent bubbling typically indicates that air is escaping from the pleural cavity or there is a problem with the tubing or chest tube placement. This is the first sign that the system may not be sealed properly and should be checked for leaks.

B. The water levels in the water-seal chamber and suction chambers are decreased: Decreased water levels in both the water-seal and suction chambers may be indicative of fluid loss or evaporation, but it does not necessarily point to a leak. In the case of a chest tube, water levels may also drop due to suction pressure or gradual evaporation, which would need to be adjusted or monitored. While this should be addressed, it is not an immediate cause for suspicion of an air leak in the system.

C. Fluid in the water-seal chamber fluctuates with the client's breathing: The fluctuation (also known as "tidaling") in the water-seal chamber is a normal finding that occurs when the client breathes in and out. It reflects the pressure changes in the pleural cavity during respiration. The absence of tidaling might indicate that the lung has re-expanded or that there is a blockage in the tubing. While tidaling is a normal occurrence, the absence or abnormality of this fluctuation would require further assessment but not for an air leak.

D. There is constant bubbling in the suction-control chamber: Constant bubbling in the suction-control chamber generally indicates that suction is appropriately applied to the system. However, if there is continuous bubbling in this chamber, it is typically related to the level of suction being applied, not an air leak. This is a normal occurrence and does not require checking for leaks in the system unless suction pressure is too high or low for optimal functioning.

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Correct Answer is C

Explanation

A. Call for the rapid response team and request a portable chest X-ray: While calling for assistance and obtaining a chest X-ray is important for further assessment, the immediate priority is to secure the wound to prevent air from entering the pleural space. This action will help stabilize the patient until the rapid response team arrives and the X-ray can be performed.

B. Turn the suction drainage system off and auscultate breath sounds: Turning off the suction and auscultating breath sounds may be necessary after the wound is secured, but these actions should not take priority over sealing the chest tube site. The focus at this moment is to prevent a tension pneumothorax by sealing the dislodged chest tube site. Auscultation of breath sounds is useful afterward to assess for respiratory complications, but it is not the first action to take.

C. Apply a sterile dressing and tape on three sides: The first action when a chest tube becomes accidentally dislodged is to seal the opening to prevent air from entering the pleural space, which could lead to a pneumothorax (collapsed lung). Applying a sterile dressing and taping it on three sides helps create a temporary one-way valve effect, allowing air to escape from the pleural space but preventing further air from being drawn in. This intervention is crucial to stabilize the patient while awaiting further evaluation and intervention.

D. Notify the healthcare provider immediately: Notifying the healthcare provider is essential, but it is not the first action. The most important initial step is to seal the chest tube site to prevent further complications. After the dressing is applied, the nurse can then notify the healthcare provider and continue to monitor the patient.

A. Guidewire-induced dysrhythmia B. Pneumothorax C. Pulmonary infarction D. Venous thrombosis

Correct Answer is B

Explanation

A. Guidewire-induced dysrhythmia: Guidewire-induced dysrhythmia can occur if the guidewire or catheter irritates the heart during insertion, particularly when the catheter is placed in the central venous system. While this can lead to arrhythmias, it is typically more immediate and occurs during the procedure itself. The symptoms of dysrhythmia (e.g., irregular heartbeat) would more likely present right after insertion or during the manipulation of the guidewire. The signs of restlessness, JVD, and tachycardia observed 30 minutes after placement are more suggestive of a pneumothorax than of a guidewire-induced dysrhythmia.

B. Pneumothorax: Pneumothorax is a potential complication of central venous catheter (CVC) placement, particularly when the catheter is inserted into the subclavian vein. The right subclavian vein is located near the apex of the lung, so inadvertent puncture of the lung during catheter placement can lead to air entering the pleural space, causing a pneumothorax. The symptoms of pneumothorax may include restlessness, tachycardia, jugular vein distention (JVD), and respiratory distress. A heart rate of 120 beats per minute is consistent with tachycardia due to hypoxia or distress, and JVD can be a sign of increased intrathoracic pressure or impaired venous return, which occurs with a pneumothorax. These symptoms warrant immediate assessment for pneumothorax, which can be confirmed with a chest x-ray.

C. Pulmonary infarction: Pulmonary infarction occurs when a blockage in the pulmonary arteries prevents blood flow to lung tissue, resulting in tissue death. This can be caused by a pulmonary embolism or other issues, but it is not a typical complication of central venous catheter placement. The symptoms described (restlessness, JVD, and tachycardia) are more consistent with a pneumothorax than a pulmonary infarction, which would likely cause chest pain, hemoptysis, or dyspnea rather than these signs.

D. Venous thrombosis: While venous thrombosis (or clot formation) is a potential complication of central venous catheter placement, it typically manifests as swelling, redness, or pain at the catheter insertion site, rather than with the systemic symptoms of restlessness, tachycardia, and JVD. Venous thrombosis could cause some of the described symptoms in the long term, but it is less likely to be the cause of acute symptoms 30 minutes post-procedure. The immediate concern in this case is more likely to be pneumothorax, which can occur more suddenly and cause these symptoms.Top of FormBottom of Form

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The nurse would check for leaks in the chest tube and water seal system when:

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Naxlex Comprehensive Predictor Exams

What is the first action the nurse should take with the accidental dislodgement of a chest tube?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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