Acute Respiratory Disorders, Chest Tubes, and Mechanical Ventilation NCLEX
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
Answer: 3) Hemorrhage risk is our priority concern, due to the possibility of liver and spleen injuries. Although airway maintenance is a concern with all patients, the priority and most relevant concern with this particular patient is monitoring for signs and symptoms of hemorrhage.
Which of the following would the nurse anticipate being ordered for the patient with pulmonary contusion? SATA: A) IV fluids B) Intubation/mechanical ventilation C) Opioids D) Antibiotics E) Albumin
Answer: A, B, C, and D. IV fluids would be necessary to prevent hypovolemia because of the fluid that is leaving the vascular spaces into the lungs/pleural spaces. This must be administered judiciously to prevent fluid volume overload or worsening lung function. Intubation or mechanical ventilation may be ordered, if pulmonary contusion is severe. Opioids are often used for pain relief. Antibiotics would be administered prophylactically to prevent infection from arising. Albumin would not be given in this disorder.
The patient with flail chest has been assessed and is being monitored. The doctor has determined that there is not yet a need for endotracheal intubation. Which of the following should the nurse do to ensure prevention of the most common complication from flail chest? A) Encourage deep breathing exercises B) Teach the patient to splint the chest C) Administer O2 via nasal cannula D) Raise HOB to 30 degrees
Answer: A. Atelectasis is a very common complication from flail chest, because deep breathing and secretion removal are not occurring d/t pain while deep breathing. Splinting the chest helps with the pain, but does not directly contribute to secretion removal, which is necessary to prevent atelectasis. O2 would be important but does not help prevent a complication of broken ribs. HOB at 30 degrees does not help prevent complication in this situation.
Which of the following nursing diagnoses would be the most important yet relevant nursing diagnosis for the patient diagnosed with having a pulmonary contusion? A) Fluid Volume Overload B) Imbalanced Nutrition: Less than body requirements C) Acute Pain D) Risk for Infection
Answer: A. Fluid volume overload would be appropriate for this client because of the fluid build-up occurring in the lungs (AEB: Crackles, decreased breath sounds, etc.). This build-up is caused by the bruising and edema pulling fluid from the vascular spaces.
A patient enters the ED presenting with symptoms of shortness of breath, severe chest pain, and diminished heart sounds. His blood pressure is 90/70 and his heart rate is 110. You notice that the trachea appears to be deviated to the right. What is your nursing priority? A) Prepare for an emergency insertion of a needle into the second intercostal space, midclavicular line B) Hang IV fluids and prepare for chest tube insertion C) Encourage patient to breathe into a paper bag and obtain ABG's. D) Assess for allergies and administer epinephrine as ordered
Answer: A. This patient is presenting with symptoms of a tension pneumothorax. In this emergent situation, a needle can be inserted at the second intercostal space, midclavicular line to immediately allow some air to flow out of the pleural space. A chest tube would then be inserted. The lung re-expansion would correct the abnormal blood pressure and heart rate, and the patient does not appear to be having an allergic reaction.
The nurse should include all of the following in the plan of care for the client with a chest tube r/t hemothorax? SATA: A) Report drainage of 100 ml/hr B) Teach the patient to cough and deep breath frequently C) Report intermittent bubbling in the water seal chamber D) Keep the patient on bedrest with bedside commode E) Loop tubing to keep it off of the floor
Answer: B and c.
The nurse is taking care of the patient with an endotracheal tube who is being mechanically ventilated. Which of the following would be the best indication of the need to suction the patient? A) SpO2 level B) Quality of the breath sounds C) High pressure alarm D) Patient stating the need
Answer: B. In this situation, the patient is intubated and is being mechanically ventilated. The quality of respirations (particularly noisy respirations) are the best, most reliable indicator that the patient needs to be suctioned. SpO2 levels and the high pressure alarm might mean that the patient needs to be suctioned, but they both can mean other things. Patients who have an ETT are unable to vocally communicate this need.
The nurse knows that which of the following conditions would most likely contribute to the development of ARDS? A) Simple Pneumothorax B) Right Lobular Pulmonary Contusion C) Cardiac Tamponade D) Subcutaneous Emphysema
Answer: B. Pulmonary contusion causes fluid build-up to occur in the lungs which can in-turn impair gas exchange and and prevent oxygen and CO2 exchange. This fluid build-up can contribute to the development of ARDS (Acute Respiratory Distress Syndrome). This is the MOST likely to contribute this disorder.
You walk into the patient's room and witness the patient disconnecting the chest tube. What should the nurse do right away? A) Administer 02 and clamp the tube B) Reconnect the chest tube by using a sterile connector piece C) Call the physician D) Cover the tube with a piece of sterile gauze
Answer: B. The nurse can reconnect the chest tube by cutting the contaminated piece and using a sterile reconnecting piece to reattach the chest tube (page 317). The nurse can also place the end of the tube in sterile water. The nurse should never clamp the tube except when changing the box.
The patient has been diagnosed with having an open pneumothorax r/t penetrating injury. Which of the following symptoms would the nurse most expect to see in this patient? A) Chest pain and tracheal shifting B) Hyperresanance and hyperexpansion of the affected side C) High pitched respiratory sounds and SpO2 89% D) Muffled heart sounds and bradycardia
Answer: C. An open pneumothorax is often also known as a sucking chest wound, producing a high pitched sucking sound coming from the wound. Diminished oxygen level, hyperresanance, and chest pain would also be expected in this patient. Tracheal shifting and hyperexpansion of the lung may be seen in a tension pneumothorax (an unlikely development of an open pneumothorax). Tachycardia, rather than bradycardia would be a common symptom in pneumothorax.
The patient arrives to the ED and you are told by the reporting nurse that the patient is suspected of having flail chest. Which of the following would the nurse assess for first? A) Palpate the thorax for a crackling, grating sound B) Ask pt. pain level and location C) Monitor respirations D) Assess blood pressure and heart rate
Answer: C. In order to look for s/s of flail chest, the most important assessment sign to watch for is paradoxical chest movement, which could be found by monitoring respirations. Palpating the thorax could cause further damage to the ribs. It would be very important to assess pain and bp and hr (bleeding) but these will not help confirm the suspected diagnosis.
The nurse is taking care of the patient with a pneumothorax. Which of the following, if found in the patients history, would be most contributory to the development of this pneumothorax? A) MVA involvement approximately 2 weeks ago. B) Hx of diabetes, HTN, and asthma C) Insertion of subclavian line yesterday D) Daily use of albuterol and corticosteroid inhaler
Answer: C. Insertion of a subclavian line is often associated with traumatic pneumothorax. Some other procedures that may also cause this condition include throracentesis, endotracheal intubation, or transbronchial lung biopsy.
Your patient with chronic obstructive pulmonary disease suddenly complains of sharp pain that began with a coughing fit. You know the doctor will require the following: a) Surgical consent for lobectomy b) Nothing- this is normal c) Chest tube set-up d) Ventilator set-up
Answer: C. Patients with COPD and certain other chronic lung conditions are at a high risk for spontaneous pneumothorax. A chest tube would be needed to treat this condition.
The nursing instructor is teaching her students about the differences between ARF (Acute Respiratory Failure) and ARDS (Acute Respiratory Distress Syndrome). Which statement best describes this difference if made by the student? A) "ARF occurs in patients with chronic conditions while ARDS occurs in patients with trauma injuries" B) "They are almost the same thing except that ARDS is worse than ARF" C) "ARDS tends to occur up to a day or two after the initiating event, and unlike ARF requires mechanical ventilation to maintain oxygen status" D) "ARF is a disorder that mostly affects the breathing pattern while ARDS mostly affects the gas exchange by blocking the alveoli with fluid"
Answer: C. See page 297-299
Two days after placement of a pleural chest tube, the tube is accidentally pulled out of the chest wall. The nurse should first: a. Immerse the tube in sterile water. b. Apply an occlusive dressing such as petroleum jelly gauze. c. Instruct the client to hold their breath. d. Auscultate the lung to determine whether it collapsed.
Answer: C. To prevent air from coming into the collapsed lung with each breath, the nurse should instruct the client to hold their breath than cover the site with petroleum gauze and tape on three sides. This taping method will allow air to escape and not reenter.
You are the nursing instructor and you are taking your students to a unit where chest tubes are often in use. Which statement, if made by your students, is correct? A) "If a clot has formed in the tubing, it can be gently milked by fully completely compressing the tubing and milking it into the drainage container" B) "I should loop my patients tubing in order to keep it off of the floor" C) "Because my patient has a tube draining air out of their pleural space, it will not be necessary to have them use their incentive spirometer" D) "There can be an occasional bubble form in the water seal chamber of the chest tube"
Answer: D. An occasional bubble formed in the water seal chamber indicates that air is being released from the pleural spaces. Gentle milking of the tube may be permitted, but the tube should never be fully compressed to do it. Looping or kinking of the tube may cause a backward pressure that could impede drainage or force air back into the pleural spaces. Incentive spirometer use will help improve lung expansion.
The nurse sees the level of water in the water seal chamber rising very high. The nurse correlates which patient behavior with this rise? A) The patient is eating his lunch B) The patient is resting on his side C) The patient is squeezing the tubing D) The patient is coughing viciously.
Answer: D. Coughing, sneezing or other forces can cause an increase in negative pressure which will in turn cause an increase in the water in the water seal chamber. Eating or resting should not affect the negative pressure in the tube. Squeezing, kinking, or somehow cutting off the flow into the chest tube would increase positive pressure, not negative.
A patient has come into the ED with a hemothorax and has had a chest tube inserted 2 hours ago. Which of the following would be most concerning if observed by the nurse? A) Tidaling in the water seal of the chest tube with a popping sensation in the skin around the chest tube B) The patient is complaining of pain 8/10 and is taking shallow breaths with a RR of 27 C) There is intermittent bubbling in the water seal of the chest tube with 200 ml of bright red drainage D) The patient begins to pick at his IV lines and tries to get out of bed and is sweating profusely
Answer: D. Restlessness and Diaphoresis symptoms of hypoxemia and possible development of ARF. This requires immediate intervention. Tidaling in the water seal portion of the chest tube and subcutaneous emphysema are normal/benign findings and should be documented. Severe pain and elevated RR would be expected in this patient, but should be monitored for worsening severity. While 200 ml of bright red drainage would be expected after immediate insertion of the chest tube, intermittent bubbling would NOT be expected in the case of hemothorax. This indicates and air leak and should be investigated, but is not the most concerning in this situation.
You, the nurse, have been monitoring the client with subcutaneous emphysema around the shoulder and lower neck. You notice that the area has expanded and is traveling up the neck. Based on your knowledge, what should the nurse anticipate doing in the near future? A) Preparing the client for surgery B) Encouraging the client to use the IS C) Palpating the area D) Assisting with tracheostomy insertion
Answer: D. Subcutaneous emphysema is benign unless it spreads up into the throat and airway. In this event, a tracheostomy may need to be inserted in order to keep the airway open. Encouraging the pt. to use incentive spirometry or palpate the area will not help protect the client's airway or get rid of the subcutaneous emphysema.
The nurse and the UAP are helping to take care of the patient who is on a mechanical ventilator. Which of the following, if done by the UAP, requires intervention by the nurse? A) Once a day the UAP moves the ETT tube from one side of the mouth to the other B) The UAP monitors for any alarms coming from the machine C) Performs ROM exercises with the client D) Asks the patient to rate his pain using his marker board
Answer: D. The nurse is responsible for assessing pain on a patient, not the UAP. All other parts are fully within the UAP's scope of practice.
A thoracentesis is performed on a chest-injured client, and no fluid or air is found. Blood and fluids is administered intravenously (IV), but the client's vital signs do not improve. A central venous pressure line is inserted, and the initial reading is 20 cm H^O. The most likely cause of these findings is which of the following? A. Spontaneous pneumothorax B. Ruptured diaphragm C. Hemothorax D. Pericardial tamponade
Answer: D. The reading of CVP of 20 means that there increased venous pressure backing up because the heart is not pumping effective. This would indicate the presence of cardiac tamponade.
A nurse is caring for an agitated and anxious patient who was intubated 6 hours ago and is now on mechanical ventilation. Communication efforts to calm the patient have failed, and the nurse is now turning to pharmacological intervention. Which medication does the nurse anticipate administering? 1) Lorazepam 2) Morphine sulfate 3) Pancuronium 4) Fentanyl
1) Although Pancuronium (a neuromuscular blocking agent) CAN be used, it is best to try a sedative first. If satisfactory oxygen levels still cannot be maintained, then a neuromuscular blocking agent (WITH PAIN MEDICATION AND SEDATION!) can be used.
A nurse enters the room of a patient with a left-sided pneumothorax to perform an afternoon assessment. The nurse finds the patient's trachea deviated slightly to the right side compared to her morning findings, 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 adequately relieve the patient's shortness of breath.
A nurse is caring for a 29 year-old 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 8/10. 2) Patient reports feeling 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, even though it is slight, could be indicative of pneumonia or atelectasis. This needs to be further investigated. Crepitus and muscle spasms over the area are expected. Extreme pain is also expected, and would be the nurse's immediate concern after addressing the patient's elevated temperature.
You are taking care of the patient with an ETT. The pressure in the cuff is found to be 18 cm H2O. The nurse knows that which of the following is the greatest concern? A) Risk for bleeding B) Risk for aspiration C) Risk for tissue damage D) Risk for hypoxia
Answer: B. A normal cuff pressure is between 20-25 cmH2O. A cuff pressure of 18 would be considered to be too low, putting the client at risk for aspiration because the secretions have a way to drain down into the airway.
A nurse is monitoring a client with an oral endotracheal tube inserted that is attached to mechanical ventilation. The nurse assesses the client and notes that the client has unequal breath sounds. On the basis of this assessment finding, the nurse would first: A. Contact the physician B. Suction the endotracheal tube C. Apply humidified oxygen to the client D. Check the depth marking at the client's lips
ANSWER: D "If it is determined that breath sounds in the client with an endotracheal tube attached to mechanical ventilation are unequal, the nurse would first check the depth marking at the client's lips to evaluate the endotracheal tube for proper depth. If the tube is deeper or shallower than it should be, repositioning of the tube will be necessary. The nurse would then notify the physician, who may prescribe a chest x-ray to verify placement and then reposition the tube as needed. If the tube is displaced, suctioning the client would not remedy the problem. Humidified oxygen should already be in place for a client receiving mechanical ventilation."
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
Answer: 2 The first action by the nurse is to assess for bilateral breath sounds as an initial indication of correct tube placement. The nurse would next secure the tube and then call for chest x-ray to confirm tube placement. Once the client's airway and breathing have been attended to, then the nurse can assure the client about alternative communication means
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 her while she changes the tracheostomy ties for the first time.
Answer: 2) Excessive cuff pressure can cause tracheal necrosis, limit blood flow, and compress tracheal capillaries.
The nurse is caring for a patient with a chest tube. The nurse knows that the drainage system is working correctly if she Observes? 1. Continuous bubbling in the waterseal chamber. 2. Intermittent bubbling in the waterseal chamber. 3. No bubbling appears in the suction chamber. 4. Titling is absent in the waterseal chamber.
Answer: 2. Intermittent or occasional bubbling in the water seal chamber is to be expected. If the bubbling increases or becomes continuous this would be indicative of an airleak. There should be continuous, gentle bubbling in the suction seal chamber. Tilting would not be expected.
A 19 year-old patient being administered PEEP begins to have copious amounts of secretions that she says she "just 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.
Answer: 3) At this time, the nurse should 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.
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.
Answer: 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.
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
Answer: 4) An ambu bag and suction catheters/suction sources must be at the bedside of patients with artificial airways.
Beep Beep Beep. The high pressure alarm is sounding in the patient's room. Which of the following is the most likely cause. A) The ventilator tubing has become disconnected B) The patient is trying to talk to his friend C) There is a leak in the cuff D) The patient is c/o pain 9/10
Answer: B. High pressure alarms sound when anything is blocking the air from going down the tube. Some possible causes include biting the tube, excess secretions, kinking, condensation in tubing, the patient gagging, coughing, or talking, or a more serious complication like pneumothorax or bronchospasm. Disconnected tubing would most likely set off a low pressure alarm. A leak in the cough would prevent all the air to go into the lungs efficiently. Pain itself would not affect the pressure.
The student nurse diligently assesses her patient with a chest tube. She notices that the suction control chamber of the chest tube is not bubbling. What is the first thing this student should do? A) Document this normal finding B) Encourage the patient to cough and deep breathe C) Check the level of the suction on the wall D) Clamp the chest tube and call for help
Answer: C. The level of suction is controlled by the amount of water in the suction control chamber. However, it would be prudent of the student nurse to check and see if the suction is even turned on. This portion of the chest tube should be gently bubbling, indicating the system is working. Coughing and deep breathing would not help turn the suction on. The student should never clamp the chest tube.
Which of the following ABG values would the nurse expect to see on the patient with Acute Respiratory Failure? A) pH 7.35 B) O2 72 C) HCO3 26 D) PCO2 55
Answer: D. A PCO2 level of over 50 is one of the criteria for classifying/diagnosing ARF. Others include a pH below 7.35 and an O2 below 50. The HCO3 can be elevated (for compensation) or normal depending on the person and the state of the respiratory failure
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
Answer: D. This amount of drainage would be expected, and most likely increase r/t repositioning of the client.
Which assessment would be a priority for evaluating the status of a pleurevac connected to a right middle lobe chest tube? A. Incentive spirometry B. Breath sounds C. Chest tube drainage D. Chest X-ray
The correct answer is D. The chest X-ray will be able to visualize fluid and air in the pleural space. Options A, B, C would be beneficial to evaluate but are not as inclusive as option D.
