The nurse is assessing a client with a chest tube for crepitus. Which assessment technique is most appropriate for the nurse to perform?
A. Press down on the client’s abdomen, releasing, and assessing for pain.
[2%]
B. Palpate the skin around the chest tube and observe for a crackling sensation.
[75%]
C. Auscultating the bowel sounds in each quadrant.
[7%]
D. Inspect the client’s chest for an even rise and fall.
[15%]
Statistics
Subject/Lesson
Subject
Adult Health
Lesson
Respiratory
Client Need
Test Plan
Reduction of Risk Potential
Related Topic
Potential for Complications of Diagnostic Tests/Treatments/Procedures
Item Type
Item Type
Knowledge/Comprehension
Explanation
Choice B is correct. The nurse may assess for crepitus by palpating the skin around the chest tube and observing for a crackling sensation. Crepitus is defined as infiltration of air in the subcutaneous layer of the skin, also known as subcutaneous emphysema. It is caused by air leaking into the subcutaneous space.
Choice A is incorrect. When the nurse presses down on a client's abdomen and then releases it, the nurse is assessing for rebound tenderness. This occurs when pain is present upon letting go of the client's abdomen, not pressing inward; this is a sign of peritonitis.
Choice C is incorrect. Auscultating the bowel sounds in each quadrant is not an appropriate way to assess for crepitus.
Choice D is incorrect. Inspecting the client's chest for even rise and fall will not allow the nurse to monitor for crepitus; rather this will help the nurse to assess for a symmetrical chest and unlabored breathing.
NCSBN Client Need: Topic: Reduction of Risk Potential, Subtopic: System Specific Assessments, Respiratory
