Certified Emergency Nurse (CEN) Practice Test

When assessing a chest tube with FOCA, which factor should NOT be monitored?

1. Fluctuations

2. Output

3. Color

4. Blood Pressure

The correct answer is: Blood Pressure

When assessing a chest tube using the FOCA (Fluctuations, Output, Color, and Air Leak) criteria, it is essential to focus on factors directly related to the tube's function and the patient's respiratory status. Monitoring fluctuations assesses the presence of any movement in the water seal chamber, indicating changes in intrapleural pressure. Observing output provides valuable information about fluid drainage, which is crucial for assessing the patient’s condition and preventing complications. Evaluating the color of the output can help in determining the nature of the fluid being drained, aiding in the diagnosis and management of potential issues such as hemorrhage or infection. In contrast, blood pressure is not a factor considered in this specific assessment of a chest tube. While vital signs, including blood pressure, are important in the overall assessment of a patient in an emergency setting, they do not directly pertain to the function and evaluation of the chest tube itself. Monitoring blood pressure relates more to the patient's hemodynamic stability rather than the effectiveness of the chest tube. Therefore, it is appropriate to focus only on the factors that directly pertain to the chest tube when using the FOCA criteria.