Chapter 21med surge
The system has an air leak.
Constant bubbling in the chamber often indicates an air leak and requires immediate assessment and intervention.
A patient is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching includes what?
Correct use of incentive spirometry Instruction in the use of incentive spirometry begins before surgery to familiarize the patient with its correct use
The nurse is discussing activity management with a patient who is postoperative following thoracotomy. What instructions should the nurse give to the patient regarding activity immediately following discharge?
Perform shoulder exercises five times daily. The nurse emphasizes the importance of progressively increased activity
The decision has been made to discharge a ventilator-dependent patient home. The nurse is developing a teaching plan for this patient and his family. What would be most important to include in this teaching plan?
Signs of pulmonary infection
The nurse caring for a patient with an endotracheal tube recognizes several disadvantages of an endotracheal tube. What would the nurse recognize as a disadvantage of endotracheal tubes?
The cough reflex is depressed.
Disadvantages include suppression of the patient's cough reflex, thickening of secretions, and depressed swallowing reflexes. Ulceration and stricture of the larynx or trachea may develop,
What would the critical care nurse recognize as a condition that may indicate a patient's need to have a tracheostomy?A patient requires permanent ventilation
A patient recovering from thoracic surgery is on long-term mechanical ventilation and becomes very frustrated when he tries to communicate. What intervention should the nurse perform to assist the patient?
Express empathy and then encourage the patient to write, use a picture board, or spell words with an alphabet board.
The nurse is caring for a patient who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning the patient from a ventilator, the nurse is aware that the weaning of the patient will progress in what order?
Removal from the ventilator, tube, and then oxygen
Postural drainage has been ordered for a patient who is having difficulty mobilizing her bronchial secretions. Before repositioning the patient and beginning treatment, the nurse should perform what health assessment?
Chest auscultation
Chest drainage systems are used in treatment of spontaneous pneumothorax and trauma resulting in pneumothorax
The home care nurse is visiting a patient newly discharged home after a lobectomy. What would be most important for the home care nurse to assess?
Wait several minutes and then repeat suctioning.
A nurse has performed tracheal suctioning on a patient who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention?
Signs and symptoms of respiratory complications
A patient has been discharged home after thoracic surgery. The home care nurse performs the initial visit and finds the patient discouraged and saddened. The client states, "I am recovering so slowly. I really thought I would be better by now." What nursing action should the nurse prioritize?
The nurse is preparing to suction a patient with an endotracheal tube. What should be the nurse's first step in the suctioning process?
Assess the patient's lung sounds and SAO2 via pulse oximeter.
A patient's plan of care specifies postural drainage. What action should the nurse perform when providing this noninvasive therapy?
Assist the patient into a position that will allow gravity to move secretions.
The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess?
Baseline arterial blood gas (ABG) levels
The nurse is preparing to discharge a patient after thoracotomy. The patient is going home on oxygen therapy and requires wound care. As a result, he will receive home care nursing. What should the nurse include in discharge teaching for this patient?
Correct and safe use of oxygen therapy equipment
CPAP allows a lower percentage of oxygen to be used with a similar effect.
Prevention of oxygen toxicity is achieved by using oxygen only as prescribed
The home care nurse is planning to begin breathing retraining exercises with a client newly admitted to the home health service. The home care nurse knows that breathing retraining is especially indicated if the patient has what diagnosis?COPD
The nurse is performing nasotracheal suctioning on a medical patient and obtains copious amounts of secretions from the patient's airway, even after inserting and withdrawing the catheter several times. How should the nurse proceed?
Breathe in deeply through the spirometer, hold your breath briefly, and then exhale."
The patient should be taught to lace the mouthpiece of the spirometer firmly in the mouth, breathe air in through the mouth,
If the patient uses an alternative method of communication, he will feel in better control and likely be less frustrated
The physician has ordered continuous positive airway pressure (CPAP) with the delivery of a patient's high-flow oxygen therapy. The patient asks the nurse what the benefit of CPAP is. What would be the nurse's best response?
A patient with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the physician to order?
Venturi mask The Venturi mask is used primarily for patients with COPD because it can accurately provide an appropriate level of supplemental oxygen, thus avoiding the risk of suppressing the hypoxic drive
While caring for a patient with an endotracheal tube, the nurses recognizes that suctioning is required how often?
When adventitious breath sounds are auscultated Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are present.
A patient in the ICU has had an endotracheal tube in place for 3 weeks. The physician has ordered that a tracheostomy tube be placed. The patient's family wants to know why the endotracheal tube cannot be left in place. What would be the nurse's best response?
When an endotracheal tube is left in too long it can damage the lining of the windpipe."
A nurse educator is reviewing the indications for chest drainage systems with a group of medical nurses. What indications should the nurses identify? Select all that apply.
Chest trauma resulting in pneumothorax Post thoracotomy Spontaneous pneumothorax
The nurse is caring for a patient who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. What method of oxygen delivery is most appropriate for the patient's needs?
Nasal cannula A nasal cannula is used when the patient requires a low to medium concentration of oxygen for which precise accuracy is not essential
Oxygen toxicity can occur when patients receive too high a concentration of oxygen for an extended period.
Symptoms of oxygen toxicity include dyspnea, substernal pain, restlessness, fatigue, and progressive respiratory difficulty
A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this patient is necessary. What is the main rationale for this?
Maintaining a patent airway
The nurse is caring for a patient who is scheduled to have a thoracotomy. When planning preoperative teaching, what information should the nurse communicate to the patient?How to splint the incision when coughing
Prior to thoracotomy, the nurse educates the patient about how to splint the incision with the hands, a pillow, or a folded towel.
The OR nurse is setting up a water-seal chest drainage system for a patient who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system?
20 cm H2O The amount of suction is determined by the water level. It is usually set at 20 cm H2O; adding more fluid results in more suction
Chest auscultation should be performed before and after postural drainage in order to evaluate the effectiveness of the therapy
A nurse is teaching a patient how to perform flow type incentive spirometry prior to his scheduled thoracic surgery. What instruction should the nurse provide to the patient?
The nurse is caring for a client with an endotracheal tube who is on a ventilator. When assessing the client, the nurse knows to maintain what cuff pressure to maintain appropriate pressure on the tracheal wall?
Between 15 and 20 mm Hg
The nurse observes that the water level in the water seal rises and falls in rhythm with the patient's respirations. How should the nurse best respond to this assessment finding?
Document that the chest drainage system is operating as it is intended.
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient has been receiving high-flow oxygen therapy for an extended time. What symptoms should the nurse anticipate if the patient were experiencing oxygen toxicity?
Dyspnea and substernal pain
The nurse is performing patient education for a patient who is being discharged on mini-nebulizer treatments. What information should the nurse prioritize in the patient's discharge teaching?
How to perform diaphragmatic breathing Diaphragmatic breathing is a helpful technique to prepare for proper use of the small-volume nebulizer
The critical care nurse is precepting a new nurse on the unit. Together they are caring for a patient who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff?
Monitor the pressure in the cuff at least every 8 hours
Pulmonary function studies
Pulmonary function studies are performed to determine whether the planned resection will leave sufficient functioning lung tissue
A nurse is educating a patient in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the patient and the family that this drainage system is used for?
Removing excess air and fluid Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood.
The nurse has explained to the patient that after his thoracotomy, it will be important to adhere to a coughing schedule. The patient is concerned about being in too much pain to be able to cough. What would be an appropriate nursing intervention for this client?
Teach him how to perform huffing. The technique of "huffing" may be helpful for the patient with diminished expiratory flow rates or for the patient who refuses to cough because of severe pain
Assessment data indicate the need for suctioning and allow the nurse to monitor the effect of suction on the patient's level of oxygenation
The critical care nurse and the other members of the care team are assessing the patient to see if he is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify?
A tracheostomy permits long-term use of mechanical ventilation to prevent aspiration of oral and gastric secretions in the unconscious or paralyzed patient.
The medical nurse is creating the care plan of an adult patient requiring mechanical ventilation. What nursing action is most appropriate?Monitor cuff pressure every 8 hours.
The process of withdrawing the patient from dependence on the ventilator takes place in three stages: the patient is gradually removed from the ventilator, then from the tube, and, finally, oxygen.
The nurse has admitted a patient who is scheduled for a thoracic resection. The nurse is providing preoperative teaching and is discussing several diagnostic studies that will be required prior to surgery. Which study will be performed to determine whether the planned resection will leave sufficient functioning lung tissue?
and hold the breath at the end of inspiration for about 3 seconds. The patient should then exhale slowly through the mouthpiece
The nurse is assessing a patient who has a chest tube in place for the treatment of a pneumothorax.
The home care nurse is assessing a patient who requires home oxygen therapy. What criterion indicates that an oxygen concentrator will best meet the needs of the patient in the home environment?
The patient desires a portable oxygen delivery system that can deliver 2 L/min. They can deliver oxygen flows from 1 to 10 L/min and provide an FiO2 of about 40%
Measure the patient's oxygen saturation
The patient's response to suctioning is usually determined by performing chest auscultation and by measuring the patient's oxygen saturation
Provide emotional support to the patient and family
The recovery process may take longer than the patient had expected, and providing support to the patient is an important task for the home care nurse.
Postural drainage is usually performed two to four times per day. The patient uses gravity to facilitate postural draining.
The skin should be covered with a cloth or a towel during percussion to protect the skin
A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube?
To remove air from the pleural space Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood.
Before weaning a patient from mechanical ventilation, it is most important to have baseline ABG levels. During the weaning process
While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of the patient's closed chest-drainage system. What should the nurse conclude?
Cuff pressure must be monitored by the respiratory therapist or nurse at least every 8 hours
by attaching a handheld pressure gauge to the pilot balloon of the tube or by using the minimal leak volume or minimal occlusion volume technique
Stable vital signs and ABGs
Among many other predictors, stable vital signs and ABGs are important predictors of successful weaning