1.1 Trach Care and Chest Tubes

A nurse auscultates a clients lung fields. Which pathophysiologic process should the nurse associate with this breath sound? (Click the media button to hear the audio clip.) a. Inflammation of the pleura b. Constriction of the bronchioles c. Upper airway obstruction d. Pulmonary vascular edema

ANS: A A pleural friction rub can be heard when the pleura is inflamed and rubbing against the lung wall. The other pathophysiologic processes would not cause a pleural friction rub. Constriction of the bronchioles may be heard as a wheeze, upper airway obstruction may be heard as stridor, and pulmonary vascular edema may be heard as crackles. REF: 590

A nurse auscultates a clients lung fields. Which action should the nurse take based on the lung sounds? (Click the media button to hear the audio clip.) a. Assess for airway obstruction. b. Initiate oxygen therapy. c. Assess vital signs. d. Elevate the clients head.

ANS: A Stridor is the sound heard, and it indicates severe airway constriction. The nurse must administer a bronchodilator to get air into the lungs. Administering oxygen, assessing vital signs, and elevating the clients head will not help until the clients airways are open. REF: 590

A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed? a. Applying suction while inserting the catheter b. Preoxygenating the client prior to suctioning c. Suctioning for a total of three times if needed d. Suctioning for only 10 to 15 seconds each time

ANS: A Suction should only be applied while withdrawing the catheter. The other actions are appropriate. REF: 540

An unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse takes priority? a. Assess the clients lung sounds. b. Assign a different UAP to the client. c. Report the UAP to the manager. d. Request thicker liquids for meals.

ANS: A The priority is to check the clients oxygenation because he or she may have aspirated. Once the client has been assessed, the nurse can consult with the registered dietitian about appropriately thickened liquids. The UAP should have reported the incident immediately, but addressing that issue is not the immediate priority. REF: 539

A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the clients face is puffy and the eyelids are swollen. What action by the nurse takes priority? a. Assess the clients oxygen saturation. b. Notify the Rapid Response Team. c. Oxygenate the client with a bag-valve-mask. d. Palpate the skin of the upper chest.

ANS: A This client may have subcutaneous emphysema, which is air that leaks into the tissues surrounding the tracheostomy. The nurse should first assess the clients oxygen saturation and other indicators of oxygenation. If the client is stable, the nurse can palpate the skin of the upper chest to feel for the air. If the client is unstable, the nurse calls the Rapid Response Team. Using a bag-valve-mask device may or may not be appropriate for the unstable client. REF: 538

A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client? (Select all that apply.) a. Cognition b. Dexterity c. Hydration d. Range of motion e. Vision

ANS: A, B, D, E The older adult is at risk for having impairments in cognition, dexterity, range of motion, and vision that could limit the ability to perform tracheostomy care and should be assessed. Hydration is not directly related to the ability to perform self-care. REF: 544

A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the client maintain self-esteem? (Select all that apply.) a. Create a communication system. b. Dont go out in public alone. c. Find hobbies to enjoy at home. d. Try loose-fitting shirts with collars. e. Wear fashionable scarves.

ANS: A, D, E The client with a tracheostomy may be shy and hesitant to go out in public. The client should have a sound communication method to ease frustration. The nurse can also suggest ways of enhancing appearance so the client is willing to leave the house. These can include wearing scarves and loose-fitting shirts to hide the stoma. Keeping the client homebound is not good advice. REF: 543

A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best? a. Elevate the head of the clients bed. b. Measure and compare cuff pressures. c. Place the client on NPO status. d. Request that the client have a swallow study.

ANS: B Constant pressure from the tracheostomy tube cuff can cause tracheomalacia, leading to dilation of the tracheal passage. This can be manifested by food particles seen in secretions or by noting that larger and larger amounts of pressure are needed to keep the tracheostomy cuff inflated. The nurse should measure the pressures and compare them to previous ones to detect a trend. Elevating the head of the bed, placing the client on NPO status, and requesting a swallow study will not correct this situation. REF: 538

While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first? a. Assess for drainage from the site. b. Cover the insertion site with sterile gauze. c. Contact the provider and obtain a suture kit. d. Reinsert the tube using sterile technique.

ANS: B Immediately covering the insertion site helps prevent air from entering the pleural space and causing a pneumothorax. The area will not reseal quickly enough to prevent air from entering the chest. The nurse should not leave the client to obtain a suture kit. An occlusive dressing may cause a tension pneumothorax. The site should only be assessed after the insertion site is covered. The provider should be called to reinsert the chest tube or prescribe other treatment options. REF: 593

A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority? a. Administer prescribed anxiolytic medication. b. Ensure informed consent is on the chart. c. Reinforce any teaching done previously. d. Start the preoperative antibiotic infusion.

ANS: B Since this is an operative procedure, the client must sign an informed consent, which must be on the chart.Giving anxiolytics and antibiotics and reinforcing teaching may also be required but do not take priority.

A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met? a. The client demonstrates good understanding of stoma care. b. The client has joined a book club that meets at the library. c. Family members take turns assisting with stoma care. d. Skin around the stoma is intact without signs of infection.

ANS: B The client joining a book club that meets outside the home and requires him or her to go out in public is the best sign that goals for Impaired Self-Esteem are being met. The other findings are all positive signs but do not relate to this nursing diagnosis. REF: 543

A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply.) a. Production of pink sputum b. Tracheal deviation c. Sudden onset of shortness of breath d. Pain at insertion site e. Drainage of 75 mL/hr

ANS: B, C Tracheal deviation and sudden onset of shortness of breath are manifestations of a tension pneumothorax. The nurse must intervene immediately for this emergency situation. Pink sputum is associated with pulmonary edema and is not a complication of a chest tube. Pain at the insertion site and drainage of 75 mL/hr are normal findings with a chest tube. REF: 594

A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurses immediate intervention? (Select all that apply.) a. Production of pink sputum b. Tracheal deviation c. Pain at insertion site d. Sudden onset of shortness of breath e. Drainage greater than 70 mL/hr f. Disconnection at Y site

ANS: B, D, E, F Immediate intervention is warranted if the client has tracheal deviation because this could indicate a tension pneumothorax. Sudden shortness of breath could indicate dislodgment of the tube, occlusion of the tube, or pneumothorax. Drainage greater than 70 mL/hr could indicate hemorrhage. Disconnection at the Y site could result in air entering the tubing. Production of pink sputum, oxygen saturation less than 95%, and pain at the insertion site are not signs/symptoms that would require immediate intervention. REF: 594

The nurse is caring for a client with lung cancer who states, I dont want any pain medication because I am afraid Ill become addicted. How should the nurse respond? a. I will ask the provider to change your medication to a drug that is less potent. b. Would you like me to use music therapy to distract you from your pain? c. It is unlikely you will become addicted when taking medicine for pain. d. Would you like me to give you acetaminophen (Tylenol) instead?

ANS: C Clients should be encouraged to take their pain medications; addiction usually is not an issue with a client in pain. The nurse would not request that the pain medication be changed unless it was not effective. Other methods to decrease pain can be used, in addition to pain medication. REF: 591

A nurse cares for a client who has developed esophagitis after undergoing radiation therapy for lung cancer. Which diet selection should the nurse provide for this client? a. Spaghetti with meat sauce, ice cream b. Chicken soup, grilled cheese sandwich c. Omelet, soft whole wheat bread d. Pasta salad, custard, orange juice

ANS: C Side effects of radiation therapy may include inflammation of the esophagus. Clients should be taught that bland, soft, high-calorie foods are best, along with liquid nutritional supplements. Tomato sauce may prove too spicy for a client with esophagitis. A grilled cheese sandwich is too difficult to swallow with this condition, and orange juice and other foods with citric acid are too caustic. REF: 591

A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor? a. Holding the device securely when changing ties b. Suctioning the client first if secretions are present c. Tying a square knot at the back of the neck d. Using half-strength peroxide for cleansing

ANS: C To prevent pressure ulcers and for client safety, when ties are used that must be knotted, the knot should be placed at the side of the clients neck, not in back. The other actions are appropriate. REF: 542

A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply.) a. Administer prescribed salmeterol (Serevent) inhaler. b. Assess the client for a tracheal deviation. c. Administer oxygen to keep saturations greater than 94%. d. Perform peak expiratory flow readings. e. Administer prescribed albuterol (Proventil) inhaler.

ANS: C, E Suprasternal retraction caused by inhalation usually indicates that the client is using accessory muscles and is having difficulty moving air into the respiratory passages because of airway narrowing. Wheezing indicates a narrowed airway; a decreased pulse oxygen saturation also supports this finding. The asthma is not responding to the medication, and intervention is needed. Administration of a rescue inhaler is indicated, probably along with administration of oxygen. The nurse would not do a peak flow reading at this time, nor would a code be called. Midline trachea is a normal and expected finding. REF: 590

A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. Which action should the nurse take? a. Ambulate the client in the hallway to promote deep breathing. b. Auscultate the clients anterior and posterior lung fields. c. Encourage the client to take shallow breaths to help with the pain. d. Administer pain medication and encourage the client to take deep breaths.

ANS: D A chest tube is placed in the pleural space and may be uncomfortable for a client. The nurse should provide pain medication to minimize discomfort and encourage the client to take deep breaths. The other responses do not address the clients discomfort and need to take deep breaths to prevent complications. REF: 595

A nurse cares for a client who has a chest tube. When would this client be at highest risk for developing a pneumothorax? a. When the insertion site becomes red and warm to the touch b. When the tube drainage decreases and becomes sanguineous c. When the client experiences pain at the insertion site d. When the tube becomes disconnected from the drainage system

ANS: D Intrathoracic pressures are less than atmospheric pressures; therefore, if the chest tube becomes disconnected from the drainage system, air can be sucked into the pleural space and cause a pneumothorax. A red, warm, and painful insertion site does not increase the clients risk for a pneumothorax. Tube drainage should decrease and become serous as the client heals. Sanguineous drainage is a sign of bleeding but does not increase the clients risk for a pneumothorax. REF: 593

A nurse cares for a client who has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment? a. Strip the tubing to minimize clot formation and ensure patency. b. Secure tubing junctions with clamps to prevent accidental disconnections. c. Connect the chest tube to wall suction at the level prescribed by the provider. d. Keep padded clamps at the bedside for use if the drainage system is interrupted.

ANS: D Padded clamps should be kept at the bedside for use if the drainage system becomes dislodged or is interrupted. The nurse should never strip the tubing. Tubing junctions should be taped, not clamped. Wall suction should be set at the level indicated by the devices manufacturer, not the provider. REF: 593

. A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the clients pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate? a. Call the operating room to inform them of a pending emergency case. b. No action is needed at this time; this is a normal finding in some clients. c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask. d. Stay with the client and have someone else call the provider immediately.

ANS: D This client may have a tracheainnominate artery fistula, which can be a life-threatening emergency if the artery is breached and the client begins to hemorrhage. Since no bleeding is yet present, the nurse stays with the client and asks someone else to notify the provider. If the client begins hemorrhaging, the nurse removes the tracheostomy and applies pressure at the bleeding site. The client will need to be prepared for surgery. REF: 538