There is a good chance that you’ll encounter at least one chest tube-related question on the NCLEX, so it is important to be prepared. I personally found chest tubes to be a somewhat tricky subject back when I was a nursing student. So you may want to spend some extra time studying this subject to make sure you’re well-versed.
Below, I will be walking you through two NCLEX questions that are related to chest tubes and sharing the correct answers along with explanations for both.
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Question 1
The nurse assists the client in receiving a chest tube placement in the inferior right lung lobe. Which assessment is the priority for the nurse?
Answers:
A. Pulse
B. Pain
C. Pulse oximetry
D. Temperature
Before delving into the correct answer, I’ll first take some time to go through the incorrect answers and explain why they are incorrect.
Option A: Pulse
Taking the pulse of the patient would be useful, but it is not the first step you should take. This is because the pulse is used to assess the patient’s circulation, but the priority in this situation relates to respiratory health. This is not the correct answer.
Option B: Pain
Once again, pain is important to assess but it is not the priority assessment. This is not the correct answer.
Option D: Temperature
Checking the patient’s temperature would usually be done to check for signs of infection. Infection won’t occur until 24 to 48 hours after the chest tube has been inserted, so this wouldn’t be useful to check at this time. This is not the correct answer.
Option C: Pulse oximetry
Pulse oximetry assesses how well your patient is breathing. This is an important assessment to perform since it assesses respiratory function. This is the correct answer.
Understanding priority assessment
This question used a concept called “priority assessment” to determine the correct answer. Priority assessment for a chest tube patient can easily be remembered by using the acronym ABC, which stands for airway, breathing, and circulation. These are the most important things to assess for the patient, and they should be done in that order. So, first, you’ll want to assess the airway, followed by breathing, followed by circulation.
When reviewing the answer options for this question, there isn’t an answer that applies to the airway, so the next step would be to assess breathing. The pulse oximeter assesses breathing, so this would be the correct answer.
You can also see that this is the correct answer because since the question is asking about a chest tube, you’ll want your nursing assessment to focus on the respiratory system. Pulse oximetry is the only option that focuses on assessing the respiratory system, so this is another way to arrive at the correct answer.
Question 2
The nurse cares for a client with a chest tube connected to a dry suction drainage device. During the assessment, the nurse notes that the chest tube is dislodged from the insertion site. Which is the nurse’s priority action?
Answers:
A. Push the chest tube back into the insertion site.
B. Cover the insertion site with dry adhesive gauze.
C. Cover the site securely with petroleum gauze.
D. Cover the site with a damp gauze pad soaked in sterile saline.
Option A: Push the chest tube back into the insertion site.
A nurse should never re-insert a chest tube that has become dislodged. Once the chest tube has moved out of the pleural space, it is no longer sterile. If it is inserted back in, it could lead to a serious infection. The health care provider is responsible for re-inserting the chest tube using a sterile technique at the bedside or using imaging devices with interventional radiology. This is not the correct answer.
Option B: Cover the insertion site with dry adhesive gauze.
Dry gauze should not be used to cover the insertion site since this can cause air to enter the pleural space. This can cause a tension pneumothorax, which can be life-threatening. This is not the correct answer.
Option D: Cover the site with a damp gauze pad soaked in sterile saline.
Placing damp gauze over the site also presents the same risk as using dry gauze. Because of the risk of air getting in the pleural space, you would not want to use damp gauze. This is not the correct answer.
Option C: Cover the site securely with petroleum gauze.
The correct answer is option C. If a chest tube becomes dislodged, the appropriate action from the nurse is to cover the insertion site with an occlusive, petroleum gauze dressing, followed by a dry sterile dressing and occlusive tape. Once these steps are complete, the nurse is to immediately notify the healthcare provider so that they can re-insert the chest tube. Chest tube dislodgement is considered an emergency because the patient is at risk of air entering the pleural space which can cause a tension pneumothorax.
What do nurses need to know about chest tube management?
Going into taking the NCLEX, you’re going to want to sit down and familiarize yourself with a variety of important nursing concepts and interventions. When it comes to chest tubes, there is quite a bit to be aware of.
Something that is very important to know about is how to properly assess a patient who has a chest tube and what to focus on during your nursing assessment.
The nursing process for chest tubes
When applying the nursing process to chest tube patients, consider the following.
- Nursing assessments should focus on the respiratory system such as checking lung sounds, using the pulse oximeter, and evaluating the patient’s breathing.
- Monitoring a patient with a new chest tube should involve checking the blood pressure and pulse, level of consciousness, and ability to breathe independently.
- You should be observing your patient for signs of infection such as elevated temperature, redness, swelling, drainage from the insertion site, increased heart rate, or low blood pressure.
- Nurses are in charge of monitoring the fluid intake and output of a chest tube.
- Patient comfort is also important. After safety has been established, you can support the patient’s comfort through proper positioning and pain relief.
What to know about chest tubes for NCLEX
Chest tubes are a pretty complex subject, requiring detailed study time to understand the many different types and chambers that they connect to. You’ll also want to have some understanding of how chest tubes work and why a patient may get one.
A chest tube may be placed in the pleural space of the lung to help the lung re-expand by removing air or fluid. It may also be placed in the mediastinum to drain blood or fluid from around the heart, following heart surgery.
Common reasons a patient might require a chest tube include:
- Heart surgery
- Pneumothorax (collapsed lung)
- Pleural effusion (fluid in the pleural space)
This only scratches the surface of chest tube knowledge that may help you succeed on NCLEX. Spend some time studying the subject of chest tubes because there is a lot to learn. Make sure you’re focusing on patient safety and priority assessments in order to prepare yourself for chest tube questions on the NCLEX.
Takeaways
You’re bound to care for a chest tube patient at some point during your nursing career. Similarly, there is a good chance that you’ll encounter a chest tube question (or two) on the NCLEX. Because chest tubes can be a tricky and fairly complicated subject, it is advisable to dedicate sufficient study time to chest tubes when studying for NCLEX. In addition to studying the actual subject matter, you’ll also want to do some practice questions that help you with critical thinking and prioritizing patient care. This holistic approach will not only prepare you for the NCLEX but also for real-life scenarios you’ll face in your nursing career.
