Chapter 21 (Test 3)
The nurse is preparing to perform chest physiotherapy (CPT) on a patient. Which of the following patient statements would indicate the procedure is contraindicated.
"I just finished eating my lunch, I'm ready for my CPT now."
A client has been placed on a ventilator, and the spouse is visiting for the first time. The spouse begins to cry. The best statement by the nurse is
"Tell me what you are feeling"
A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings?
84 mm Hg
Constant bubbling in the water seal of a chest drainage system indicates which of the following problems?
Air leak
Which of the following is a potential complication of a low pressure in the ET cuff?
Aspiration pneumonia
Which ventilator mode provides full ventilatory support by delivering a present tidal volume and respiratory rate?
Assist-control
A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned?
Auscultate the lung for adventitious sounds.
For a client with an endotracheal (ET) tube, which nursing action is the most important?
Auscultating the lungs for bilateral breath sounds
A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs?
Auscultation
Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain?
Baseline arterial blood gas (ABG) levels
A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client?
By supplying a magic slate or similar device
A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse
Continues assessing the client's respiratory status frequently
A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition?
Hypoxia
The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique?
Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes.
A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?
Manual resuscitation bag
For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?
Measuring and documenting the drainage in the collection chamber
The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia?
PaO2
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?
Partial pressure of arterial oxygen (PaO2)
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?
Suction the client's artificial airway
The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for:
Symmetry of the clients chest expansion
The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient?
The patient is hypoxic from suctioning
Which of the following is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means?
Venturi mask
Which type of ventilator has a present volume of air to be delivered with each inspiration?
Volume controlled
After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes?
Water seal chamber