Respiratory NCLEX Review
A nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects. The initial nursing action is to: 1. Call the physician. 2. Place the tube in a bottle of sterile water. 3. Immediately replace the chest tube system. 4. Place a sterile dressing over the disconnection site.
2)
A nurse enters the room of a patient with a left-sided pneumothorax to perform an assessment. The nurse finds the patient's trachea deviated slightly to the right side, and the patient reports feeling increasingly short of breath. What is the first action the nurse should take? 1) Administer high-flow supplemental oxygen. 2) Position the patient's HOB at 30-45 degrees. 3) Call the physician. 4) Document the extent of tracheal shift in the patient's chart and reassess in 15 minutes.
1) High-flow supplemental oxygen should be administered immediately to offset the unavoidable result of hypoxemia. The nurse should also ensure a POX is applied. Adjusting the HOB will not do much to decrease the patient's shortness of breath.
A nurse responds to a low-pressure ventilator alarm in a patient's room and cannot determine what is causing the alarm. Which action by the nurse is priority? 1) Disconnect the ventilator and bag the patient. 2) Call a code and begin chest compressions. 3) Contact respiratory therapy for a STAT consult. 4) Contact the physician after documenting that all connections have been checked.
1) Priority is the patient's immediate airway needs.
The nurse enters the patient's room at the beginning of her shift. The patient is 3 days post-op right-sided pneumonectomy. Which of the following findings requires most immediate intervention by the nurse? 1) The patient is slowly sipping iced water. 2) The CNA reports that urinary output for the last 6 hours is 200 mL. 3) The patient is positioned on her left side with SCDs in place. 4) The patient reports pain at 9/10.
3) The post-op pneumonectomy patient should be positioned on the OPERATIVE (bad) side OR on the back. Sipping iced water in itself isn't harmful to this patient. Urinary output is sufficient. Pain is expected, although this would be the nurse's second concern.
Which of the following assessment findings in a client with a closed chest tube drainage should concern the nurse most? a) continuous, vigorous bubbling in the suction control chamber b) continuous, gentle bubbling in the suction control chamber c) continuous fluctuations of fluid along the tube in the water-seal chamber d) absence of bubbling in the water-seal chamber
a)
The nurse caring for patients in the ICU knows that which position often improves respiratory status in patients with ARDS? 1) supine 2) high-fowler's 3) prone 4) lithotomy
3)
What is a normal PEEP level? 1) 1 2) 2 3) 5 4) 6
3) A normal PEEP is 5
The nurse is caring for a patient after undergoing a right thoracotomy. When caring for this patient with a chest tube, the nurse should: A. Clamp the tube once per day B. Milk the chest tube to facilitate draining C. Notify the physician if there are fluctuations in the water seal chamber D. Encourage deep breathing and coughing
D)
The nurse assists the physician with the removal of a chest tube. Before the physician removes the chest tube, which instruction should the nurse give to the client? a. "Exhale and bear down." b. "Hold your breath for 5 seconds." c. "Inhale and exhale rapidly." d. "Cough as hard as you can."
a.)
Which of the following sets of values indicate acute respiratory failure? Select all that apply 1) PaCO2 of 62 2) PaO2 of 54 3) arterial pH 7.39 4) arterial pH 7.15 5) PaO2 71
1, 4 CO2 must be above 50. O2 must be below 50. pH must be below 7.35
A client with a closed chest drainage system tries to get out of bed alone and disconnects the chest tube from the drainage system, which falls on the floor. Which of the following actions should the nurse take first upon entering the client's room? 1. Submerge the tube in sterile water or saline 2. Set up and attach a new closed chest drainage system 3. Assess the client's respiratory status 4. Check the client's pulse and blood pressure
1. The priority action of the nurse is to submerge the tube in sterile water or saline to reestablish the underwater seal. This will prevent the client from sucking air through the chest tube into the pleural space during inspiration, thereby causing pneumothorax. After this initial action, the nurse would assess the client's respiratory status, set up a new system, and then check the client's full vital signs before reporting incident to the physician
Two days after placement of a pleural chest tube, the tube is accidentally pulled out of the chest wall. The nurse should first: 1. Immerse the tube in sterile water. 2. Apply an occlusive dressing such as petroleum jelly gauze. 3. Instruct the client to cough to expand the lung. 4. Auscultate the lung to determine whether it collapsed.
2)
Which test does the nurse know will best aid in the diagnosis of acute respiratory distress syndrome (ARDS)? 1) STAT CT without contrast 2) Chest X-ray 3) V/Q ratio exam 4) ABG draw STAT
2) CXR A stat CT is not necessary. ABG draws are necessary, but this is not as diagnostic or as emergent as obtaining a CXR for a patient who is short of breath.
A patient admits to the E.D. She is grasping her chest and tells you she feels "shaken up and weird" and can't breathe. She is extremely diaphoretic and her vitals are as follows: 98.8, 117, 29, 146/54. Her expected diagnosis is acute respiratory distress syndrome. Which of the following orders does the nurse recognize as priority for this patient? 1) 8L of O2 via nonrebreather mask 2) prepare the patient for endotracheal intubation and mechanical ventilation 3) lab draws q 2 hours to monitor respiratory status 4) monitor respiratory status q 15 minutes
2) prepare for intubation and mechanical ventilation
A 72 year-old COPD patient has been ventilator-dependent for 5 days, and begins to question if the usage is still necessary. He writes a question for the nurse that says "what will help me get off this ventilator?" Which of the following responses by the nurse is INCORRECT? Select all that apply 1) "Stable vital signs are one way we determine your readiness to leave the ventilator." 2) "As long as we feel that your ABG results have improved from the beginning of your treatment, we will remove you." 3) "We do not like to remove patients from the ventilator until they have been stable for a minimum of 3-5 days." 4) "A group of individuals in your healthcare team will collaborate to determine the safest and earliest time possible to remove you from the ventilator." 5) "Because we've seen improvement in your COPD the past few days, this is a good indicator that you may be ready for removal from the ventilator."
2, 3 1) Correct. 2) Incorrect- ABG results need to be stable for the proper gas exchange. The baseline is important, but a slight improvement isn't reason to remove the patient from the ventilator. 3) Incorrect- There is no minimum time a patient should be on a ventilator, but we don't like them using ventilators longer than 10 days. After that time, we'd consider a tracheostomy. 4) Correct. 5) Correct. Improvement in patient condition that caused the need for the ventilator is something we look for.
A nursing student has been educated on the importance of preventing VAP. Which of the following statements, if made by the student, is correct? Select all that apply 1) "It is important to keep the patient's HOB between 45 and 60 degrees to prevent aspiration and secretion build-up." 2) "The patient should have a 'sedation vacation check' at least every 24 hours to check the patient's ability to breathe on his own." 3) "Sterile gloves should be worn when the nurse makes contact when the patient or the ventilator." 4) "Oral care should be provided at least every 8 hours with chlorahexadine." 5) "It is important to ensure that patients on a ventilator have orders for DVT prophylaxis."
2, 5 1) Incorrect. The HOB should be between 30 and 45 degrees. 2) Correct 3) Incorrect. The nurse should wash his/her hands with soap and water or use an alcohol-based hand rub. 4) Incorrect. Oral care needs to be performed more regularly, at LEAST every 4 hours. 5) Correct. Also, we're probably going to make sure a peptic ulcer prophylactic like Protonix is ordered.
The mother of a 6-year-old female with a new tracheostomy says, "why is that gunk you suction out so thick? Is my daughter getting sick?" Which response by the nurse is most appropriate? 1) "Respiratory therapists usually make rounds between 9 and 11am, but I can call them early to answer your questions." 2) "Because your daughter is lying on her back, her secretions tend to pool and accumulate to become thicker." 3) "Because the air your daughter is getting is not going through her nose and upper airway, the secretions tend to be thicker without that added humidity." 4) "This is a very common finding in trach patients, and I promise you have nothing to worry about."
3)
A nursing student is assigned a patient on mechanical ventilation who has been diagnosed with ARDS. Which finding by the student nurse requires an intervention by the primary R.N.? 1) The patient is lying in the prone position. 2) The patient's PaO2 result on his chart is 66 mm Hg. 3) The patient is resting quietly. 4) The patient's O2 saturation is 87%.
4) This requires intervention and investigation on behalf of the primary nurse. We are aiming for an oxygen saturation of at least 90% and a PaO2 of at least 60 mm Hg.
A nurse is told that an assigned client will have the chest tubes removed. In preparation for the procedure, the nurse plans to : 1. Clamp the chest tubes. 2. Disconnect the drainage system. 3. Empty the drainage system. 4. Administer pain medication 30 minutes before the procedure.
4)
A nursing student asks her instructor, "why would tidaling cease in a water seal chamber? Is this a bad thing?" Which of the following reasons does NOT contribute to lack of tidaling in the water seal chamber: 1) The lung has reexpanded 2) There is a loop of tubing below the rest of the tubing. 3) Wall suction is not working properly. 4) There is an air leak
4) An air leak would be represented by excessive or new bubbling in the water seal chamber.
A nurse is caring for a client who has a chest tube. The nurse notes that the chest tube has become disconnected from the chest drainage system. What is the priority nursing action? A. Reposition the client to a high fowler's position. B. Increase the suction to the chest drainage system. C. Place the client on low flow oxygen via nasal cannula. D. Immerse the end of the chest tube in a bottle of sterile water
D.
The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300mL. The nurse should give priority to: A. Turning the client to the left side B. Milking the tube to ensure patency C. Slowing the intravenous infusion D. Notifying the physician
D.
Which assessment would be a priority for evaluating the status of a pleurevac connected to a right middle lobe chest tube? A. Incentive spiometry B. Breath sounds C. Chest tube drainage D. Chest X-ray
D.
Which of the following measures best determines that a patient who had a pneumothorax no longer needs a chest tube? A. You see a lot of drainage from the chest tube. B. Arterial blood gas (ABG) levels are normal. C. The chest X-ray continues to show the lung is 35% deflated. D. The water-seal chamber doesn't fluctuate when no suction is applied.
D.
Which should the nurse expect to observe in the water - seal chamber of the chest tube drainage system for a client with a hemothorax 4 hours after chest tube insertion? A. No movement of the fluid B. Bloody drainage C. Vigorous bubbling D. Fluctuation with inspiration and expiration.
D.
The client pulls out the chest tube and fails to report the occurrence to the nurse. When the nurse discovers the incidence, he should take which initial action? ❍ A. Order a chest x-ray ❍ B. Reinsert the tube ❍ C. Cover the insertion site with a Vaseline gauze ❍ D. Call the doctor
C)
The nurse is caring for a client who is post-op following a thoracotomy. The client has 2 chest tubes in place, connected to 1 chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the most appropriate nursing action? A) Clamp the chest tube B) Call the surgeon immediately C) Continue to monitor the client to see if the bubbling increases D) Instruct the client to try to avoid coughing
C)
A client has a chest tube in place following a left lower lobectomy done after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the MOST appropriate nursing action? a. Clamp the chest tube b. Call the surgeon immediately c. Prepare for blood transfusion d. Continue to monitor the rate of drainage
d.
Which of the following FiO2 values is inconsistent with the diagnostic findings of a patient with ARDS? 1) 150 mm Hg 2) 95 mm Hg 3) 199 m Hg 4) 225 mm Hg
4) Should be below 200 mm Hg.
A nurse enters the room of a patient with a new tracheostomy. The nurse obtains a set of vitals to see that the patient's HR is elevated to 84 from his baseline of 60-65 BPM. The patient's respirations are 26 and noisy, and he is moving around restlessly in bed. Which action by the nurse is appropriate at this time? 1) Obtain a stat CXR order. 2) Suction the patient. 3) Encourage the patient to cough and deep breathe q 2 hours. 4) Obtain a second set of vital signs for confirmation.
2) The nurse's assessment findings indicate that the patient needs to be suctioned. Following agency protocol.
The nurse enters a patient's room to find his tracheostomy tube dislodged. There is no replacement tube at the bedside, and the patient appears to be in severe respiratory distress. Which action by the nurse is most important at this time? 1) Spread the tracheostomy opening with retention sutures grasped. 2) Cover the stoma with a sterile dressing and ventilate with a bag-mask while calling for help. 3) Position the patient in semi-Fowler's position. 4) Search for an obtutator.
2) There is no need to spread the tracheostomy opening, because there is no spare tube at the bedside- same with the obturator, pointless without a spare tube. Positioning the patient in semi-Fowler's position might be more appropriate if the level of respiratory distress was minimal.
A nurse has just administered a paralytic medication to a client who is ventilator-dependent. Which finding by the nurse is most concerning? 1) The patient's HR has dropped from 79 to 61. 2) The patient's potassium is 5.9. 3) The patient received morphine sulfate 10 minites before the paralytic. 4) The patient has a standing order for Romazicon and Narcan.
2) Paralytics must not be given to patients with hyperkalemia. It is expected that paralytics will cause bradycardia, and this can be corrected with an anticholinergic.
A nursing instructor is educating a group of students about the advantages of a tracheostomy over an endotracheal tube. Which of the following is NOT an advantage of a tracheostomy? 1) The patient has increased comfort but is still at risk for infection. 2) The patient is less mobile, but has more choices available. 3) The patient can eat. 4) There is less risk of long-term damage to the airway.
2) The patient is MORE mobile with a tracheostomy than with an endotracheal tube/ventilator.
The nurse is caring for a patient with a water seal chest drainage system. Which assessment finding requires further investigation by the nurse? 1) The collection chamber has 125 mL of bloody drainage. 2) The water in the water seal chamber is bubbling. 3) The water in the suction chamber is bubbling. 4) There is tidaling present in the water seal chamber.
2) Bubbling is normal in the suction control chamber, but this indicates an air leak of present in the water seal chamber. Tidaling in the water seal chamber is normal and represents inhalation and expiration.
The nurse is caring for a patient with a tracheostomy tube. Which action, if performed by the nurse, is incorrect and requires intervention from the charge nurse? 1) The nurse suctions the patient's airway when she hears noisy respirations. 2) The nurse inflates the trach cuff to 30 cm H2O. 3) The nurse ensures that there is an obturator at the patient's bedside. 4) The nurse asks that another nurse help him while he changes the tracheostomy ties for the first time.
2) Incorrect. Excessive cuff pressure can cause tracheal necrosis, limit blood flow, and compress tracheal capillaries.
What effect might low cuff pressure have on a patient with an endotracheal tube? 1) necrosis 2) pneumonia 3) tracheal bleeding 4) ischemia
2) pneumonia If the cuff pressure is too low, secretions can leak into the lungs and cause aspiration and/or pneumonia.
The client has just had emergency intubation for respiratory distress. Immediately after endotracheal tube insertion, which of the following actions by the nurse is most appropriate? 1. Tape the tube securely in place 2. Assess for bilateral breath sounds 3. Call for chest x-ray to determine placement 4. Assure the client that alternative communication means will be provided
2.
The nurse is caring for a patient diagnosed with a pneumothorax who had chest tubes inserted four hours ago. There is no fluctuating (tidaling) in the water-seal compartment of the closed chest drainage system. Which action should the nurse implement first? 1. Milk the chest tube. 2. Check the tubing for kinks. 3. Instruct the patient to cough. 4. Assess the insertion site.
2.
A nurse begins his shift and is assigned a patient with a simple right-sided pneumothorax. The nurse enters the room and finds the following assessment pieces. Which is most concerning? 1) The patient has an order for 3L of continuous O2 and is not wearing her nasal canula. 2) The patient is attempting to get out of bed to use the bedside commode. 3) The patient is yelping and says her pain is a 5/10. 4) The patient's trachea is deviated from midline to the left side.
4) This indicates that a tension pneumothorax has probably developed.
What cardiac effects does the use of positive-pressure ventilation have? 1) increased preload and decreased afterload 2) increased preload and decreased CO 3) decreased preload and decreased CO 4) increased BP and decreased CO
3)
At what point should an endotracheal tube sit? 1) 1-5 cm below the carina 2) 0.5-1 cm above the carina 3) 2-6 cm above the carina 4) 0.5-1 cm below the carina
3) A tube pushed below the carina (and almost always into the right bronchus) will only inflate the R lung.
A new nurse has just assisted with the intubation of a 46 year-old male. Which action should the nurse take FIRST? 1) Provide oral care with chlorahexadine swabs q 4 hours and PRN. 2) Consult imaging for a portable X-ray machine. 3) Auscultate bilateral breath sounds. 4) Obtain an Ambu bag from the PAR closet and place it at the patient's bedside.
3) First, the nurse needs to ASSESS the success of the intubation. This is also done via portable CXR (option 2), but auscultation can be performed quicker and will be done first, along with watching the symmetry of chest expansion. The nurse would then obtain a chest X-ray, and gather supplies that are required at the patient's bedside.
A nurse is caring for a patient on a med-surg unit with 3 lower rib fractures. Which of the following findings, if noted by the nurse, is most concerning? 1) patient rates pain 6/10 2) patient reports muscle spasms over the fracture area when he coughs 3) patient's temperature is 99.8F 4) the nurse feels a crackling, grating sensation over the lower ribs.
3) This patient has spiked a fever which could be indicative of pneumonia or atelectasis. This needs to be further investigated. Crepitus and muscle spasms over the area are expected. Pain is also expected.
A 19 year-old patient being administered PEEP begins to have a copious amount of secretions that she says she cannot cough up. Which of the following nursing actions is most appropriate at this time? 1) Assess the patient further and utilize bedside suction equipment. 2) Assess O2 sats and continue to monitor patient if results are 95% or above. 3) Obtain respiratory therapy consult. 4) Obtain an order for a mucolytic agent from the physician.
3) Obtain a respiratory therapy consult Any break in the closed ventilator system causes the loss of PEEP, so respiratory therapy needs to be consulted to add in-line suctioning.
A patient admits to the E.D. with fractures of 3 lower ribs. Which of the following is the priority concern of the nurse caring for this patient? 1) infection risk 2) pain 3) hemorrhage risk 4) airway maintenance
3) hemorrhage risk, due to the possibility of liver and spleen injuries.
Which of the following are effects seen on patients who are ventilator-dependent? Select all that apply 1) increased cardiac output 2) consistent hypertension 3) increased intracranial pressure 4) hypervolemia 5) DVTs
3, 4, 5 1) INCORRECT. Because there is super high pressure in the pulmonary tree, the blood has to pump against this and it's hart to get out to the body. If there is less blood going out to the body, there is less coming back into the heart. Hense, we see DECREASED cardiac output. 2) INCORRECT. This goes with the decreased cardiac output piece. We CAN see hypertension, but this is not a "given."
A student nurse prepares to suction a patient with a tracheostomy for the first time. Which action, if made by the student nurse, requires correction from the instructor? Select all that apply 1) The student nurse ensures that the suction source pressure does not exceed 150 mm Hg. 2) The student nurse suctions a small amount of sterile water before beginning the procedure. 3) The student nurse picks up the connecting tubing with his dominant hand. 4) The student nurse provides 100% oxygen to the patient for 30 seconds after he finishes suctioning. 5) The student nurse turns on suctioning and enters the catheter with his dominant hand until resistance is felt, then pulls back 1-2 cm.
3, 5 1) Correct. 2) Correct. This ensures equipment is working properly. 3) INCORRECT. Connecting tubing is picked up with the non-dominant hand. 4) Correct. 5) INCORRECT. Suctioning should NOT be applied while inserting the catheter. The student nurse is correct to use his dominant hand and insert until resistance is felt before pulling back 1-2 cm.
A nurse is caring for a patient who has been diagnosed with a pulmonary contusion. Which assessment data obtained by the nurse most warrants an immediate intervention? 1) Diminished breaths sounds 2) The patient has a constant, mostly-dry cough 3) The patient occasionally coughs up blood-tinged sputum 4) The patient's O2 sats are 88%.
4) Diminished breath sounds, a constant dry cough, and blood-tinged secretions are all expected assessment findings for a patient with a pulmonary contusion. Along with respiratory acidosis, pain, tachypnea, and tachycardia. An O2 saturation of 88% indicated hypoxemia and warrants intervention on the nurse's behalf. Which intervention? Supplemental oxygen.
A nurse knows that which of the following is the most important item required at the bedside of a patient with an endotracheal tube at all times? 1) A 4x4 piece of sterile gauze and a 100 mL container of sterile water. 2) A portable chest X-ray machine with a lead vest. 3) A soft-bristled toothbrush and chlorahexadine-based oral care supplies. 4) An Ambu bag
4) An ambu bag and suction catheters/suction sources must be at the bedside of patients with artificial airways.
A registered nurse (RN) is working with a licensed practical nurse (LPN) and assistive personnel (AP). Which of the following clients should be assigned to the LPN? A. A client who had a left hip arthroplasty yesterday and is requesting oral medication for pain every 4 hours. B. A client with non-displaced fractures of the radius and ulna being transferred from the emergency department. C. A client who is newly admitted with right flank pain and needs to have a urinalysis specimen collected and sent to the lab. D. A client who had a chest tube inserted an hour ago and has 200 mL sanguineous drainage in the chest tube collection system.
a.
