Author Question: A nurse determines that there may be a leak in the chest tube system. Clamps are applied near the ... (Read 25 times)

leo leo · **on:** Jul 23, 2018

A nurse determines that there may be a leak in the chest tube system. Clamps are applied near the client's chest, and the nurse finds that the bubbling stops. The nurse should:

A. Change the tubing
B. Change the drainage container
C. Move the clamps farther down the chest tube
D. Reinforce the dressing and notify the physician

Question 2

Positioning of a client after chest tube insertion for a hemothorax is:

A. Supine
B. Side-lying
C. Semi-Fowler's
D. High-Fowler's

amy.lauersdorf90 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

D
D. Assess for the location of the air leak by clamping chest tube close to the chest wall with two shodded hemostats. If the bubbling stops, the leak is inside the thorax or insertion site. Unclamp the tube, reinforce the dressing, and notify the physician immediately.
A. If bubbling continues with the clamps near the chest wall, gradually move one clamp at a time down the tubing away from the client. If bubbling stops, replace the tubing or secure the connections.
B. If bubbling continues with the clamps near the chest wall, gradually move one clamp at a time down the tubing away from the client. If bubbling continues, replace the drainage system.
C. If bubbling continues with the clamps near the chest wall, gradually move one clamp at a time down the tubing away from the client. If bubbling stops, replace the tubing or secure the connections. If bubbling continues, replace the drainage system.

Answer to Question 2

D
D. Client is in high-Fowler's position to drain fluid (hemothorax).
A. After the tube is placed, assist client to a comfortable position. Supine does not facilitate drainage or removal of air.
B. After the tube is placed, assist client to a comfortable position. Side-lying does not facilitate drainage or removal of air.
C. Client is in semi-Fowler's to high-Fowler's position to evacuate air (pneumothorax).