Resp Exam 2

The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs?

Aspiration of gastric contents occurs when suctioning.

The nurse is assigned to assist in caring for a client diagnosed with a pneumothorax who has a chest tube connected to a closed-chest drainage system. The client asks the nurse why a chest tube was inserted. Which response by the nurse explains the purpose of a chest tube?

"To allow for reexpansion of the lung."

Proper Suctioning steps include?

1. Hyperoxgenate the client before suctioning 2. Apply suction for up to 10 seconds 3. Advance the catheter until resistance is met and then pull the catheter back 1cm 4. Apply intermittent suction while rotating and withdrawing the catheter. Never apply suctioning while inserting the catheter

The nurse is planning to suction a client through a tracheostomy tube. Which is the amount of time for application of suction during withdrawal of the catheter?

10 Seconds

The nurse determines that which client is at greatest risk for development of acute respiratory distress syndrome (ARDS)?

A client with pancreatitis and gram-negative sepsis.

The emergency department nurse is caring for a client who sustained a blunt injury to the chest wall. Which sign noted in the client indicates the presence of a pneumothorax?

Dyspnea

The nurse is told that an assigned client will have the chest tubes removed. The nurse plans to do which in preparation for the procedure?

Administer pain medication 15 to 30 minutes before the procedure.

The nurse has finished suctioning a client. The nurse should use which parameters to bestdetermine the effectiveness of suctioning?

Breath sounds are clear.

The nurse checks a closed chest tube drainage system on a client who had a lobectomy of the left lung 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. Which should the nurse do first?

Check for kinks in the chest drainage system.

The nurse is performing nasopharyngeal suctioning on a client and suddenly notes the presence of bloody secretions. Which action should the nurse implement?

Check the amount of suction pressure being applied

The nurse is performing nasotracheal suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which observation is made?

Coughing occurs while suctioning

The nurse is assisting a client with a closed chest tube drainage system to get out of bed to a chair. During the transfer, the chest tube gets caught in the leg of the chair and accidentally dislodges from the insertion site. Which action should the nurse implement?

Cover the insertion site with sterile gauze.

The nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes the presence of an audible wheeze. The nurse attempts to remove the suction catheter from the client's trachea but is unable to do so. What is the nurse's priority response?

Disconnect the suction source from the catheter.

The nurse is assessing a client with multiple traumas who is at risk for developing acute respiratory distress syndrome (ARDS). The nurse should assess for which earliest sign of acute respiratory distress syndrome?

Increased Respiratory Rate

The nurse is assessing a client with multiple traumas who is at risk for developing acute respiratory distress syndrome (ARDS). The nurse should assess for which earliest sign of acute respiratory distress syndrome?

Increased respiratory rate

A client with right pleural effusion by chest x-ray is being prepared for a thoracentesis. The client experiences dizziness when sitting upright. The nurse assists the client to which position for the procedure?

Left side-lying with the head of the bed elevated at 45 degrees.

The nurse is reviewing the record of a client with acute respiratory distress syndrome (ARDS). The nurse determines that which finding documented in the client's record is consistent with the most expected characteristic of this disorder?

Low Arterial of Pao2 of 48

A client who has just suffered a flail chest is experiencing severe pain and dyspnea. Which would be the appropriate nursing action?

Notify the RN

The nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. After immediately applying sterile gauze over the chest tube insertion site which should the nurse do next?

Notify the RN. We do not replace the chest tube.

A primary health care provider is about to remove a chest tube from a client. Once the dressing is removed and the sutures have been cut, the nurse assisting the primary health care provider asks the client to do which action?

Perform the Valsalva maneuver.

A client has a chest tube that is attached to a chest drainage system. The chest tube becomes disconnected. What should the nurse do immediately?

Put the open end under sterile water.

The nurse is caring for a client who is being treated for a pneumothorax with a closed chest tube drainage system. When repositioning the client, the chest tube disconnects. Which nursing action should be immediate?

Reattach the chest tube to the drainage system.

A client has just returned from intrathoracic surgery where a chest tube was placed. The nurse notes a small amount of serosanguineous drainage on the chest tube's dressing. Which action should the nurse take?

Reinforce the dressings because a small amount of serosanguineous drainage is normal after surgery.

The nurse is monitoring a client following a motor vehicle crash. Which finding would indicate a need for chest tube placement?

Shortness of breath and tracheal deviation

The nurse is suctioning a client through a tracheal tube. During the suctioning procedure, the nurse notes on the cardiac monitor that the heart rate has dropped 10 beats. Which should be the nurse's next action?

Stop the procedure and oxygenate the client.

The nurse is caring for a client with an endotracheal tube attached to a ventilator. The high-pressure alarm sounds on the ventilator. The nurse prepares to perform which priority nursing intervention?

Suction the client

The nurse is monitoring a client with a closed chest tube drainage system and notes fluctuation of the fluid level in the water-seal chamber during inspiration and expiration. On the basis of this finding, which conclusion should the nurse make?

The chest tube is functioning as expected.

The nursing student and clinical instructor are performing tracheotomy suction at the bedside of an adult client with a tracheostomy. Which action by the nursing student is incorrect, causing the clinical instructor to intervene?

The student suctions the client's tracheotomy tube for 15 seconds.

The nurse checks the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. Based on this finding, the nurse makes which determination?

The system is functioning as expected.

A client is admitted to the nursing unit following a lobectomy. The nurse caring for the client notes that, in the first hour after admission, the chest tube drainage was 75 mL. During the second hour, the drainage dropped to 5 mL. Which finding does this indicate?

The tube may be occluded.

A client had thoracic surgery 2 days ago and has a chest tube in place connected to a closed chest tube system. The nurse notes continuous bubbling in the water seal chamber. The nurse determines which?

There is a leak in the system that requires immediate investigation and correction.

A client who is postoperative with incisional pain complains to the nurse about completing respiratory exercises. The client is willing to do the deep breathing exercises but states that it hurts to cough. The nurse provides gentle encouragement and appropriate pain management to the client, knowing that coughing is needed for which reason?

To expel mucus from the airways

A client experiencing a pleural effusion had a thoracentesis. Analysis of the extracted fluid revealed a high red blood cell count. The nurse interprets that this result is consistent with which diagnosis?

Trauma

PEEP pressure

Treatment for ARDS. Maintains the patients airway pressure above the atmospheric level exerting pressure that opposes passive emptying of the lung.

The nurse is reviewing the record of a client with acute respiratory distress syndrome (ARDS). The nurse determines that which finding documented in the client's record is consistent with the mostexpected characteristic of this disorder?

rterial Pao2 of 48

The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which action should the nurse take?

Monitor vital signs and discontinue attempts at suctioning until the client is stabilized.

The nurse is suctioning an adult client through a tracheostomy tube. During the procedure, the nurse notes that the client's oxygen saturation by pulse oximetry is 89%. Which action should the nurse implement?

Stop the suctioning procedure.

The nurse is preparing to perform nasotracheal suctioning on a client. The nurse places the client's bed in which position to effectivelyperform this procedure?

The client is placed in the Fowler's position for nasotracheal suctioning. This position promotes lung expansion and is also the preferred position for eating and nasogastric tube insertion.