Simple Nursing: Congenital heart defects, stroke, PE, chest tubes

The nurse is assessing the chest tube drainage of a patient with a hemothorax following a motor vehicle accident. Which findings will be expected in a normally functioning chest tube system? Select all that apply. A. Presence of an occlusive dressing over the insertion area B. Tidaling in the water-seal chamber with respirations C. Continuous bubbling in the water seal chamber D. 100mL sanguineous blood drainage collection chamber E. The chest tube secured to the floor beside the patient's bed

Answer: A. Presence of an occlusive dressing over the insertion area B. Tidaling in the water-seal chamber with respirations D. 100mL sanguineous blood drainage collection chamber E. The chest tube secured to the floor beside the patient's bed Incorrect: If there is continuous bubbling then these is a leak in the system. Intermittent bubbling may occur and will resolve as the lung re-expands

The nurse is preparing a room for a patient coming to her floor from the ER with the diagnosis of pulmonary embolism. Which actions by the nurse are indicated? Select all that apply. A. Raise the HOB 45 degrees B. Have incentive spirometry available C. Place intubation equipment at the bedside D. Place an IV pump in the room E. Station a bedside commode

Answer: B. Have incentive spirometry available C. Place intubation equipment at the bedside D. Place an IV pump in the room Incorrect: A. client should be in high fowlers (90 degrees) not 45 degrees E. This answer is wrong b/c there is no indication that the pt is immobile

A preceptor is teaching a nursing student about the risk factors of a hemothorax which include: Select all that apply. A. Open heart surgery B. Repetitive injury C. Blood clotting defects D. Chest trauma E. Covid-19

Answer: A, B, C, D, E -A hemothorax is when blood pools in the space between the lungs and the chest cavity. Risk factors are anything that causes blunt trauma or force to the chest wall and coagulation defects. Learning outcome: A hemothorax is when blood pools in the space between the lungs and the chest cavity. Risk factors are anything that causes blunt trauma or force to the chest wall and coagulation defects. Injury to an intercostal artery during insertion of sternal wires and central line insertion during surgery can cause a hemothorax. Repetitive injuries during athletics place the athlete at higher risks for a hemothorax due to the potential for repetitive blunt impact to the chest, abdomen, or shoulders. Blood disorders that cause prolonged clotting can cause a hemothorax. Complications of COVID-19 include thromboembolic events, emphysema, lung infections, and pulmonary embolism contribute to a hemothorax.

Which instruction(s) will help reduce the number of hypercyanotic spells in an infant with tetralogy of fallot? (Select all that apply.) A. Give a pacifier to the infant during crying spells B. Provide several small, frequent feedings per day C. Provide soothing environments upon awakening D. Swaddling during stressful times such as invasive procedures E. Turn the enfant at least every two hours during sleep.

Answer: A, B, C, and D. Giving the infant a pacifier will help to soothe and decrease the incidence of crying which competes with oxygen supply and demand. The infant will not be able to eat large meals as this will raise the need for oxygen. Small, frequent feedings will help with oxygen demand. A soothing environment will help to decrease crying which will increase oxygen demand. Swaddling can comfort the infant and possibly decrease crying which increases oxygen demand. There is no indication to turn the infant every two hours during sleep and it will increase wakefulness.

The nurse goes into the room of a patient with a chest tube. The nurse notices that the thoracic catheter has dislodged. Which action would the nurse take next? A. Cover insertion site with petroleum jelly, apply firm pressure, notify provider B. Reconnect the thoracic catheter to the tubing or suctioning using clean technique C. Obtain an order for a chest x-ray to identify malposition of the ET tube D. Administer supplemental oxygen via facemask and contact the provider

Answer: A. Cover insertion site with petroleum jelly, apply firm pressure, notify provider -A dislodged thoracic catheter is a medical emergency. If pt goes into resp. distress, call a code

The nurse is assessing a patient following a thoracentesis and immediately reports which finding to the health care provider? A. Subcutaneous emphysema around the site B. Serous drainage oozing from the site C. Increased temperature to 100.4 F / 38 C D. Diminished breath sounds on the affected side

Answer: A. Subcutaneous emphysema around the site -Find the most critical potential complication. The palpation of expanding subQ emphysema or crepitus around the thoracentesis is the most likely sign that a pneumothorax has occured. Incorrect: B. Serous drainage oozing from site is a expected finding C. A low grade fever could mean a infection but is not a priority D. Diminished breath sounds may be attributed to another condition or the procedure; however crepitus is MOST important to report.

While providing care to a patient with a chest tube drainage system, the nurse detects redness around the insertion site of the tube along with subcutaneous crepitus. Upon palpation, the patient denies any pain. Which action is best? A. Use a skin marker to identify the borders of the redness and continue to monitor B. Notify the MD of this new development C. Document findings and change the dressing D. Tape all the connections from the insertion site to the unit

Answer: A. Use a skin marker to identify the borders of the redness and continue to monitor -Maintaining skin integrity is an important part of care of the patient with a chest tube. Redness around the insertion site and crepitus indicates subcutaneous emphysema. -these are signs of subcutaneous emphysema (SCE). SCE occurs when CO2 is trapped in the subcutaneous tissues of the skin. Assessment reveals a "rice crispy" crackling sound under the skin during palpation. This is called crepitus. SCE is self-liming requiring no treatment. The nurse will notify the provider if the patient reports pain or if there is purulent drainage or odor coming from the insertion site Incorrect:

The nurse is assisting the health care provider in the removal of a chest tube. How will the nurse instruct the patient during the procedure? A. "Breathe in and out while concentrating on a fixed object in the room" B. "Hold your breathe and bear down while the tube is being removed to keep air from entering back into the area" C. "Do pursed-lip breathing then short huffing breaths while he tube is being removed to keep air from entering into the area" D. "Hold my hand and close your eyes while the tube is being removed since anxiety will cause you to breathe too quickly"

Answer: B. "Hold your breathe and bear down while the tube is being removed to keep air from entering back into the area" Explanation: Chest tubes are inserted to drain fluid or air from the pleural space in order to promote full lung reexpansion during respirations. The nurse may be asked to assist the provider with either insertion of removal. During chest tube removal, it is essential that air is prevented from entering the insertion site once the tube is removed. If air is allowed to enter the pleural space, it could result in a tension pneumothorax. The nurse should instruct the patient to hold their breath and bear down during removal to prevent this entry of air.

Which assessment finding should the nurse expect in a patient with patent ductus arteriosus (PDA)? A. A systolic murmur that is harsh sounding B. A very loud machine-like heart murmur C. A soft murmur heard only during diastole D. A murmur heard heard during systolic ejection

Answer: B. A very loud machine-like heart murmur -Patent ductus arteriosus produces turbulent blood flow which creates a loud machine-like sound. The systolic murmur occurs during systole but is not harsh sounding. PDA is heard during systole and is not a soft murmur. Murmurs heard during systole are due to aortic stenosis, anemia, or hyperthyroidism.

Which assessment finding is most closely associated with an atrial septal defect in a 2-month-old infant? A. Heart tones that are distant and muffled B. Murmur heart upon auscultation C. Sporadic hypercyanotic episodes D. Strong upper extremity pulses

Answer: B. Murmur heart upon auscultation -A murmur is heard upon auscultation at the pulmonic position during systole and diastole. Incorrect: A. Heart tones that are distant and muffled -Aortic insufficiency and some cases if mitral insufficiency are the cause C. Sporadic hypercyanotic episodes -this happens with tetralogy of fallot D. Strong upper extremity pulses -A child with atrial septal defect can experience an irregular HR/irregular pulses

A patient is brought into the emergency department with a gunshot wound to the chest. The nurse observes that the chest appears larger on one side and she hears crackling sounds as the patient breathes and the patient has jugular vein distention. The resident reports there is hyperresonance on percussion. Which action will most likely take place next? A. Placement of a sterile occlusive dressing B. Needle thoracostomy C. Immediate chest X-ray D. Placement of oxygen with a nonrebreather

Answer: B. Needle thoracostomy -Patient has S/S of a tension pneumothorax with is a life-threatening medical emergency. No time for a X-ray due to the high incidence of fatality Incorrect: A. This is done to a pneumothorax to prevent a tension pneumothorax (which the patient already has S/S of)

The nurse is caring for a patient with a pneumothorax and observes continuous bubbling in the water seal chamber. Which action by the nurse is best? A. Continue to monitor. Continuous bubbling is expected B. Notify the provider of the continuous bubbling C. Encourage coughing and deep breathing D. Change the patient's position to promote ventilation

Answer: B. Notify the provider of the continuous bubbling -A patient with a pneumothorax is expected to have intermittent bubbling in the water seal chamber as air is drained from the chest. However, continuous bubbling indicates an air leak and requires prompt attention. Incorrect:

Which patient is at the highest risk for a pulmonary embolism? A. A 67 year old pt w. exacerbation of CHF B. A 30 year old pregnant pt at 30 wks gestation C. A 59 year old patient post femur fracture D. A 45 year old on hormone replacement therapy

Answer: C. A 59 year old patient post femur fracture -This pt has 3 risk factors: age, fx of a long bone, and is immobile Overview: A pulmonary embolism (PE) is a blockage of one of the pulmonary arteries from a deep vein thrombosis that has broken off from a vein, usually in the leg. Risk factors include advanced age, congestive heart failure (CHF), pregnancy, fracture of a long bone, immobilization, and hormone replacement therapy. Incorrect: A. pt only has two risk factors: age and CHF

The emergency department nurse receives a patient with an ischemic stroke, and prepares to administer tissue plasminogen activator (t-PA). What question should the nurse ask first before administering the t-PA? A. Ask which arm or leg is affected B. Ask if speech was slurred C. Ask the time of onset of stroke D. Ask what home medications the patient takes

Answer: C. Ask the time of onset of stroke -Determines if pt is a candidate for tPA. Incorrect: -knowing meds is important, but not priority because of ABCs

A patient with dysphagia is at risk for aspiration. Which of the following instructions by the nurse is most important in helping with dysphagia after a stroke? A. Provide thin liquids until swallowing improves B. Feed the patient in bed until mobility improves C. Assist with meals and maintain patients in an upright position D. Spoon-feed all meals to ensure the patient can get enough nutrition

Answer: C. Assist with meals and maintain patients in an upright position Learning outcomes: Aspiration can occur when stomach contents enter the patient's lungs. This can cause airway obstruction, coughing, choking, decreased oxygenation, and can lead to aspiration pneumonia. Risk for aspiration is a nursing diagnosis for dysphagia. The risk of aspiration is higher with thin liquids than it is with thickened liquids. Placing the patient in an upright, 90 degree angle during mealtime, and maintaining that position for approximately 45 minutes afterwards is a prime intervention. Assistance with meals is important so as to maintain safety for the patient with dysphagia. However, dignity of risk is an important factor to consider. Encouraging the patient to use the unaffected side to feed themselves is favorable in maintaining patient's dignity.

Which action by the nurse is most appropriate when a nurse hears a loud murmur on a newbornpatient with suspected trisomy 21 who has an echocardiogram scheduled later that day? Vital signs: Blood pressure: 90/60 mm Hg Heart rate: 148/min Respirations: 44/min O 2 Sat: 97% on room air A. Quickly assist the infant to a knee-chest position B. Call for stat arterial blood gases C. Chart the findings and continue to monitor D. Contact the health care provider stat

Answer: C. Chart the findings and continue to monitor -Hypercyanotic spells can be precipitated by activity. Being able to identify and intervene early by recording and monitoring the circumstances surrounding the spells may help to decrease the incidence. The knee-chest position can help with the immediate problem but will not reduce the number of hypercyanotic spells. Arterial blood gases will be drawn and monitored but this will not reduce the number of hypercyanotic spells. The health care provider would not need to be contacted at this point.

A patient is admitted following a thrombotic stroke. What priority assessment is most important for the nurse to perform in the first 24 hours? A. A 12-lead EKG B. If bowel sounds are hypo/hyper active C. Pupil size and pupillary response D. Coagulation lab tests

Answer: C. Pupil size and pupillary response -A thrombotic stroke is caused by a blood clot that blocks an artery. Neuro assessments including pupil size and response, are imperative within the first 24 hours of a stroke to assess nerves involved. Incorrect: -12-lead EKG is not a priority assessment for a stroke pt -Bowel obstruction is important but not a priority -Coagulation lab values are not a priority. They will be obtained and monitored within 24 to 48 hours

The nurse is caring for a patient who has a chest tube following cardiac surgery and observes a dramatic decrease in chest tube drainage from the first hour to the second hour after surgery. Evaluation of the chest tube system indicates which problem? A. The lungs are not at risk and are fully inflated B. The patient is recovering without further drainage C. There may be tube obstruction due to a drainage clot. D. Tension pneumothorax is pending, so call the MD immediately

Answer: C. There may be tube obstruction due to a drainage clot. -A drastic and sudden decrease in drainage suggest a likely blockage. The first hours following cardiac surgery may have chest tube drainage as high as 100 mL/hr but should begin slowing down after a few hours, not just in the second hour Incorrect explanations: A. A sudden decrease in chest tube drainage is not an indication of lung inflation or recovery B. Drainage should not decrease so drastically so soon following cardiac surgery. A slow decrease in chest tube drainage over a period of several days is the desirable outcome that shows that recovery is taking place. D. A sudden decrease in chest tube drainage is not an indicator of tension pneumothorax. A mediastinal shift towards the unaffected side is the classic sign of a tension pneumothorax.

The nurse has completed discharged planning with her patient who was treated for a pulmonary embolism and will be on warfarin for a few more months. Which statement by the nurse indicates additional teaching is required? A. "I will replace my regular razor w/ an electric razor" B. "While traveling, I will get up and move around frequently" C. "I will continue my regular diet of learn meats, potatoes and dark leafy greens" D. "I will contact my provider if I have trouble breathing or chest pain.

Answer: D. "I will contact my provider if I have trouble breathing or chest pain. -A patient being discharged after a diagnosis of pulmonary embolism may require anticoagulation therapy post-discharge. Education on risks for bleeding, diet, and exercise will be discussed with the patient. It is important the patient understands to call 9-1-1 or go to the nearest emergency department if they exhibit any signs of a pulmonary embolism.

The nurse will collaborate with the interdisciplinary team on communication assist with a patient with expressive aphasia. The team decided on which intervention to help with communication? A. Make sure all staff know to speak slowly and in short sentences B. Make sure all staff speak loudly for the patient to hear C. Make sure all staff write on a clipboard for the patient to read communication D. Make sure all staff assist the patient with use of a picture board which is patient driven.

Answer: D. Make sure all staff assist the patient with use of a picture board which is patient driven. -Expressive aphasia is when the pt knows what they want to say, but has trouble saying it. Incorrect:

A patient is receiving continuous IV heparin for the diagnosis of pulmonary embolism (PE). Which observation by the nurse requires the IV to be stopped and a STAT aPTT level performed? A. Chills with pain and numbness in arms and legs B. Coughing productive blood-tinged sputum C. Patient complains of a headache and is sweaty D. Pinpoint-sized red and purple spots on the patient's arms and legs

Answer: D. Pinpoint-sized red and purple spots on the patient's arms and legs -While receiving anticoagulation therapy for treatment of a PE, the patient will be at risk for bleeding. The nurse shall assess for signs of bleeding which include petechiae, purpura, hematoma, and bleeding from the mucous membranes. Incorrect: A. these are S/S of HIIT B. This is a S/S of a PE, it would only be a concern if there were copious amounts of blood in the sputum C. These are S/S of hypoxia. Anticoagulation therapy wouldn't be stopped

The nurse caring for a patient who had a right wedge resection of the lung recognizes an early sign of pulmonary emboli. Which assessment finding is an early sign of pulmonary embolism? A. Cyanosis localized to the upper extremities B. Increased wheezing bilaterally C. Increase in respirations by 10 BPM over two hours D. Sudden onset of apprehension, anxiety and dyspnea.

Answer: D. Sudden onset of apprehension, anxiety and dyspnea. -A patient with a pulmonary embolus will be anxious, apprehensive, restless, and dyspneic as a result of sudden, severe hypoxemia. Incorrect: A. Cyanosis is a late sign of prolonged hypoxemia not a early sign of a PE B. Wheezing is a indicator of asthma & COPD, not a PE C. Respirations increase abruptly not slowly in a PE

A patient was brought into the ER for a stroke, but did not receive tissue plasminogen activator (tPA). Which answer below is the best rationale for this? A. The patient is on aspirin therapy B. The patient was brought in 4 hours after symptom onset. C. The patient experienced an ischemic stroke D. The patient experienced a hemorrhagic stroke

Answer: D. The patient experienced a hemorrhagic stroke -Tissue plasminogen activator (tPA) is a drug given intravenously that dissolves blood clots in ischemic strokes. It is contraindicated in patients having hemorrhagic strokes due to worsening of the bleeding. Incorrect: A. There association between aspirin and tPA treatment B. Pt was still in the window of treatment for tPA (3-4.5 hours of symptom onset)

The nurse contacts the healthcare provider about a patient's assessment following chest tube removal and reports tracheal deviation away from the affected side, agitation, and neck vein distention, all signs of a tension pneumothorax. Which action will the nurse perform while waiting for re-insertion of the chest tube? A. Release the dressing covering the open chest wound B. Administer oxygen at 80% FiO2 C. Place pt in Trendelenburg position D. Preform ABGs

Answer: insertion of the chest tube? A. Release the dressing covering the open chest wound -The focus of this question is choosing the priority action for a patient experiencing a severe complication following chest tube removal. Removal of the dressing covering the open chest wound allows air to exit the pleural space preventing worsening of the tension pneumothorax.