7th Week: M2-2.IGGY p.599,Empyema, p.622-625 Chest Trauma, Treas p.1320-1323&1309 Chest tube info, IGGY p.511 Thoracentesis_Kaplan/Picmonic Quiz

Kaplan - COPD 1. The nurse performs nutritional counseling for a patient who is diagnosed with chronic obstructive pulmonary disease (COPD). It is most important for the nurse to advise the patient to avoid consuming which nutrient in high amounts? 1. Carbohydrates. 2. Calories. 3. Protein. 4. Fats

1 1) Correct - excessive carbohydrate loads can increase carbon dioxide (CO2) production since they are broken down into glucose, CO2, and water when metabolized; this may render the COPD patient unable to exhale, and hypercapnic (increased CO2 in blood) respiratory failure could then result; COPD illness itself affects oxygen delivery to all tissues; there is decreased ability to exhange gas, decreased oxygenation in blood, increased CO2 levels in blood; COPD patients need a diet high in calories, protein, and less in carbohydrates

Kaplan - COPD 6. The nurse obtains a history from a man admitted to the hospital with chronic obstructive pulmonary disease (COPD). The nurse identifies which of the following factors is related to the patient developing COPD? 1. The patient smoked for more than 30 years. 2. The patient worked in an orchard for 20 years. 3. The patient drinks four cans of beer a day. 4. The patient had pancreatitis four times.

1 1) correct - COPD is a group of conditions associated with obstruction of air flow entering or leaving the lungs; chronic bronchitis causes excessive mucus and secretions, which block the airways; emphysema causes destruction of the walls of overdistended alveoli; smoking is the most important risk factor for COPD

Kaplan - chest tube 8. The client has three-chambered chest drainage system (Pleur-evac) in place to correct a hemothorax. Which action should the nurse take when caring for this client? 1. Assess the client's respiratory status frequently. 2. Loop any extra tubing to keep it off the floor. 3. Maintain an open drainage system. 4. Keep the client in a supine position.

1 1) correct - any client requiring a chest tube is at increased risk for developing dangerous respiratory changes and should be assessed frequently; physical assessment of respiration includes assessing respirations for rate, pattern, and depth; movements of chest wall and breath sounds are also asessed; normal adult brething is costal, regular, 12 to 20 breaths per minute; normal neonate breathing is diaphragmatic, irregular, and 30 to 50 breaths per minute; abnormal breathing patterns include: apnea, bradypnea, Cheye-Stokes respiration, dyspnea, hyperpnea, hyperventilation, hypoventilation, Kussmaul's respirations, orthopnea, and pradoxical respirations; ......

Kaplan - COPD 5. The nurse teaches pursed-lip breathing to a client diagnosed with chronic obstructive pulmonary disease (COPD). The nurse understands which is the best description of the underlying purpose of this type of breathing? 1. Prevent air trapping. 2. Strengthen oral musculature. 3. Promote deep relaxation. 4. Enhance inspiratory capacity.

1 1) correct - as air is pushed against the small opening between the lips, the resistance created goes backwards and through the airways and pushes them open throughout expiration; pursing the lips also prolongs the exhalation; all this results in a delay of airway compression or collapse, allowing more air to escape and preventing air trapping; in pursed lip breathing, the client breathes in deeply through the nose, holds it for a moment, and then exhales slowly through lips that are almost closed or pursed as if client were going to whistle; exhalation should be at least twice as long as inhalation.

Kaplan - COPD 10. The nurse teaches the client diagnosed with chronic obstructive pulmonary disease (COPD) before discharge. The client asks if the oxygen concentration can be increased during periods of shortness of breath. On which information is the nurse's response based? 1. High-flow oxygen interferes with breathing. 2. Low-flow oxygen will not improve breathing. 3. High-flow oxygen will stimulate breathing. 4. Low-flow oxygen is more comfortable.

1 1) correct - clients with COPD are stimulated to breathe, not by increasing levels of carbon dioxide, but by a decreased level of oxygen in the blood; if high-flow oxygen is provided to these clients, it eliminates their drive to breath

Kaplan - chest tube 7. An adult is in a motorcycle accident and sustains three fractured ribs and a pneumothorax. A chest tube is inserted. The nurse should take which of the following actions? 1. Monitor the fluctuation in the tube. 2. Pin the tubes to the sheets. 3. Clamp the tubes when transferring the patient to bed. 4. Empty the bottles every eight hours.

1 1) correct - closed drainage system that enables air and blood to drain from the pleural space; cessation of fluctuation may indicate blockage of the tube, or that the lung has re-expanded; fluctuation in the tube should be monitored.

Kaplan - Respiratory acute disorder 2. A patient is diagnosed with a tension pneumothorax resulting from the chest hitting the steering wheel in an automobile accident. The emergency departement nurse knows that highest priority is given to which? 1. Oxygenation 2. Chest tube insertion 3. Arterial blood gas (ABG) determination 4. Attaching a cardiac monitor

2 2) Correct - tension pneumothorax is an extremely serious emergency, even more than an open pneumothorax; motor vehicle accidents and blunt chest trauma are two potential causes; tension pneumothorax results from air moving into the pleural space and not being able to move back out; pressure builds up in the chest and if it is untreated, the heart, trachea, esophagus, and great vessels are shifted toward the unaffected side due to the lung on the affected side collapsing; further compromise of respiratory and circulatory function ensues; immediate intervention is to insert chest tubes with suction drainage in order to convert the tension pneumothorax into an open pneumothorax; thoracentesis to remove air may be used if chest tube insertion is delayed

Kaplan - Thoracentesis 4. The nurse is prepares a patient for a thoracentesis. The nurse should position the patient in which position? 1. Semi-Fowler's 2. Upright 3. On the affected side 4. Prone

2 2) correct - a thoracentesis is the aspiration of pleural fluid or air from the pleural space; sitting upright on the edge of the bed allows for the best lung expansion, and allows for good access to the area which will be used for procedure

Kaplan - chest tube 11. A patient with a chest tube asks the nurse about the bubbling he sees in the water seal chamber of his drainage equipment. Which response by the nurse is the MOST appropriate? 1. "It's supposed to do that." 2. "It shows your lung has not yet re-expanded." 3. "Why don't you ask your doctor?" 4. "What do you think it means?"

2 2) correct - this response provides a true, factual answer

Kaplan - COPD 3. The home care nurse visits the client diagnosed with chronic bronchitis. The nurse notes the client is weak and congested. It is most important for the nurse to make which statement? 1. "Cough as much as you can. The secretions have to come out." 2. "If you hold a pillow against your abdomen, the coughing will be easier." 3. "Take 3 or 4 deep breaths, and as you exhale the last breath, cough 3 times." 4. "It does not matter when you cough. Just do it."

3 3) correct - client should sit with feet on the floor, lean slightly forward, and take several slow deep breaths through the nose; exhalations should be slow and through pursed lips; during exhalation of the last breath the client should cough several times; mucus is moved up the respiratory tree more effectively with several consecutive coughs than with a single one

Kaplan - COPD 9. A patient diagnosed with chronic obstructive pulmonary disease (COPD) is drowsy and unable to expectorate secretions. The nurse should take which of the following actions? 1. Force fluids. 2. Administer high-flow oxygen via mask. 3. Perform nasotracheal suction 4. Perform postural drainage

3 3) correct - if patient unable to expectorate secretions, suctioning is appropriate; auscultate breath sounds to determine if suctioning is required

Picmonic - pneumothorax 3. During your assessment of a patient with a pneumothorax, which of the following is most likely to be seen? a. vital sign changes b. increased ICP c. visual changes d. projectile vomiting e. clubbing

a Hypotension and tachycardia are common occurances in patients that have developed a pneumothorax. Due to the increase in arterial pulmonary pressure form the collapsed lung, a decrease in blood pressure is observed. To compensate for this hypotensive state, the heart rate increases in order to maximize cardiac output and increase oxygenation.

Picmonic - chest tube 6. Which statement is most accurate? a. If drainage system is damaged, place disconnected drainage tube in sterile water b. If drainage system is damaged, occlude drainage tube with surgical tape c. If drainage system is damaged, place disconnected drainage tube in isopropyl alcohol d. If drainage system is damaged, twist drainage tube to prevent fluid loss e. If drainage system is damaged, patch any leaks in the tubing with surgical tape f. If drainage system is damaged, place disconnected drainage tube in loosely wrapped gauze

a In the event that the drainage system breaks, it is critical to have a bottle of sterile water at the bedside. If this happens, insert the loose end of the patient's chest tube into a bottle of sterile water. Keep the bottle below the level of the chest until a new drainage system can be delivered.

Picmonic - chest tube 2. What is a typical complication of inadequate chest tube dressing changes? a. infection b. increased blood lactic acid c. increased intra-abdominal pressure d. activation of clotting factors e. No PR interval f. Increased heart rate

a Keep the dressing clean, dry and intact. Monitor vital signs for acute changes, as well as the site of chest tube placement for evidence of infection. If the dressing becomes soiled, change the dressing per hospital policy.

Picmonic - pneumothorax 1. During your assessment of a patient with a pneumothorax, which of the following is most likely to be seen? a. crepitus b. meconium ileus c. steatorrhea d. increased urine output e. salty taste to skin

a Occurs in open pneumothorax. Air can become trapped in the subcutaneous tissue resulting in crepitus. Sometimes described as feeling like rice crispy treats under the skin.

Picmonic - pneumothorax 5. During your assessment of a patient with a pneumothorax, which of the following is most likely to be seen? a. tracheal deviation b. bronchial inflammation c. barking seal cough d. biliary tract inflammation e. loud snoring

a The air pressure that builds up from air not being able to escape the pleural space pushes against the trachea. On assessment the trachea will appear shifting away form the affected area.

Picmonic - pneumothorax 2. During your assessment of a patient with a pneumothorax, which of the following is most likely to be seen? a. decreased or absent breath sounds on affected side b. jugular venous distention (JVD) c. Rhonchi on unaffected side d. Inspiratory Stridor d. increased breath sounds on affected sid

a The extent of the pneumothorax will determine how much air flow will occur through the lung. breath sounds will not be heard in the lobe(s) that are fully collapsed. Take note that some patients already present with diminished lung sounds because of their anatomy.

Picmonic - pneumothorax 7. Which of the following is most likely the mechanism of pneumothorax? a. air enters pleural space b. danaged alveolar-capillary membrane c. hyperinflation and loss of elasticity d. viral infection affecting epithelial cells e. narrowed or obstructed air passage f. bacterial infection

a There are different types of pneumothorax. Howefver, they all have the same mechanism. Air or fluid enters the pleural space causing a loss in pleural space pressure resulting in the lung collapsing. A pneumothorax can be classified into either open or closed. Open pneumothorax occurs from a puncture that causes trauma to the chest wall resulting in atmospheric air entering the pleural space. This is also known as a "sucking chest wound." Closed pneumothorax can be the result of a rib fracture that lacerates the pleural wall, spontaneous rupture of a pulmonary bleb (blister-like formations on the visceral pleura), or from air entering the pleural space, but cannot escape (known as tension pneumothorax, typically from mechanical ventilation)

Picmonic - pneumothorax 10. During your assessment of a patient with a pneumothorax, which of the following is most likely to be seen? a. haemoptysis b. chest pain c. sialorrhea d. deep, slow breaths e. Rhonchi

b Can occur in all types of pneumothorax, however, pain with a pulmonary contusion is the most common. The increase in air pressure on the chest wall makes it uncomfortable and painful for the patient to take a deep breath. This is sometimes called pleuritic chest pain, which increases in intensity with each breath.

Picmonic - chest tube 8. Which finding in the suction system indicates a significant air leak? a. shortness of breath b. excessive bubbling c. No bubbling d. hypoxemia e. chest pain f. minimal bubbling

b Excessive bubbling in the water seal chamber indicates an air leak in the system. Regularly assess the system for possible causes or leaks. However, gentle intermittent bubbling should be expected with patients that have known pneumothorax.

Picmonic -chest tube 3. Which statement is most acurate? a. if the dislodges from patient, clean with alcohol solution b. if tube dislodges from patient, use petroleum gauze taped 3 ways c. if tube dislodges from patient, use zinc oxide & gauze taped 3 ways d. if tube dislodges from patient, use surgical tape over site e. if tube dislodges from patient, clean with sterile water f. if tube dislodges from patient, use regular gauze taped 3 ways

b If the chest tube dislodges from the patient, the insertion site should be covered with sterile occlusive dressing taped on 3 sides.

Picmonic - pneumothorax 6. When caring for a patient with a pneumothorax, which of the following is most likely a consideration? a. no oxygen b. high Fowler's position with oxygen c. tripod position d. left side-lying position with oxygen e. low fowler's position with oxygen f. sims position no oxygen

b It is important to keep the head of the bed elevated and place the patient in a position of comfort. Keeping the patient in a high Fowler's position puts less pressure on the lungs. Depending on the extent of the pneumothorax, oxygen needs will vary. Monitor oxygen saturation and vital signs closely for any changes.

Picmonic - Flail Chest 2. Which of the following drug classes is associated with Fail chest? a. expectorants b. analgesics c. IV antibiotics d. antibiotics e. sedatives f. barbiturate

b Pain management is essential and will allow the patient to increase the tidal volume of each breath, thereby improving ventilation and increasing oxygenation of the blood. Narcotics should be avoided, as these medications can induce respiratory depression.

Picmonic - Flail Chest 8. During your assessment of a patient with Flail chest which of the following is most likely to be seen? a. jugular venous distention (JVD) b. shallow respirations c. opisthotonus position d. widening pulse pressure e. absent or restricted movement on affected side f. muscle spasm

b Trauma to the chest wall prevents normal expansion of the lung, limiting a patient's ability to adequately ventilate. As a result, patients will likely be short of breath and breathe using rapid, shallow breaths in an attempt to compensate.

Picmonic - pneumothorax 11. During your assessment of a patient with a pneumothorax, which of the following is most likely to be seen? a. Rales on unaffected side b. absent or restricted movement on affected side c. increased movement on affected side d. barrel chest e. increased mucus production

b common with traumatic pneumothorax. Broken ribs can limit chest wall movement, known as flail chest. The patient may be splinting one side in an effort to not take a deep breath.

Picmonic - Flail Chest 1. During your assessment of a patient with Flail Chest which of the following is most likely to be seen? a. Renal failure b. Severe Headache c. Paradoxical chest movement d. Absent or Restricted movement on affected side e. Opposite side weakness (hemiplegia)

c In uninjured patients, the chest expands with inspirations, and contracts with expiration. In patient with consecutive rib fractures; however, movement of the chest is paradoxical. Patient with chest contraction during inspiration (flail area sucked in), and chest expansion (flail area bulges out) during expiration. Chest movement is asymmetric and uncoordinated.

Picmonic - chest tube 5. What is the first step in management after receiving a patient with a chest tube? a. increase suction b. change to simple masks c. confirm suction order d. change to venturi masks e. slowly change position f. confirm body alignment

c It is important to know if the drainage system should be hooked up to continuous wall suction or water seal. Also, confirm that suction control is dialed to correct pressure, and the drainage system is kept below the level of the chest.

Picmonic - Flail Chest 3. Which of the following is most likely indicated in Flail Chest? a. prepare for chest tube placement b. mannitol c. surgical rib fixation d. invasive procedures e. central venous lines f. remove or loosen restrictive items

c Surgical fixation of the ribs may be performed, as this intervention has been shown to reduce the amount of time that the patient is subjected to mechanical ventilation.

Picmonic - chest tube 1. What is the physical exam finding associated with subcutaneous emphysema? a. respiratory depression b. hematemesis c. dyspnea and respiratory distress d. crepitus e. hypertventilation f. coughing

d Crepitus occurs when gas or air leaks into the subcutaneous layer of the skin, which is a phenomenon also called subcutaneous emphysema. This can indicte an air leak or the need for a dressing change. Notify the doctor if crepitus is felt.

Picmonic -chest tube 4. Which finding should prompt urgent reevaluation of a patient with a chest tube? a. diarrhea b. dry mouth c. constipation d. arthritis e. shortness of breath f. malar rash

e Assess the patient's respiratory status regularly, and auscultate lung for any sound changes. Any clinical changes, such as the development of shortness of breath can indicate a functional problem. Air leaks, and extended pneumothorax, or a hemothorax can put the patient in respiratory distress.

Picmonic - Flail Chest 5. During your assessment of a patient with Flail Chest which of the following is most likely to be seen? a. pulmonary hypertension b. tingling lips or fingers c. pain decreased by leaning forward d. atelectasis e. chest pain f. dyspnea with exertion

e Patient with flail chest will experience sharp chest pain related to irritation of lung tissue caused by broken bones in the chest.

Picmonic - Flail chest 7. Which of the following are medication instructions or patient education points associated with Flail Chest? a. assess airway and oxygen needs b. assess for pneumothorax c. monitor plasma levels d. correct CO2 slowly e. Monitor pulmonary contusion f. monitor respiratory rate

e Pulmonary contusion is a life-threatening condition that is characterized by pooling of blood in the alveoli of the lungs after injury or trauma to the lung tissue. Patients should be monitored closely and suctioned as needed to maximize positive outcomes. Damage to the lung may also result in a pneumothorax or collapsed lung.

Picmonic - pneumothorax 9. During your assessment of a patient with a pneumothorax, which of the following is most likely to be seen? a. chronic productive cough b. ejection murmur c. increased sputum d. edema e. sudden dyspnea f. lymphedema

e The severity of the dyspnea can vary depending on the size of the pneumothorax. As the affected lobe(s) collapses, there are fewer alveoli that can participate in gas exchange. This results in the patient having rapid shallow breaths, feeling short of breath and becoming hypoxic.

Picmonic - Flail Chest 9. During your assessment of a patient with Flail Chest which of the following is most likely to be seen? a. tearing pain b. decreased PaO2 c. lightheadness d. muscle weakness e. trauma f. nausea/vomiting/anorexia

e Trauma to the chest resulting in multiple, consecutive rib fractures can cause a portion of the rib cage to detach. The resulting instability of the chest wall causes paradoxic chest movement with each breath, resulting in inadequate ventilation.

Picmonic - pneumothorax 8. When caring for a patient with a pneumothorax, which of the following is most likely a consideration? a. inhaled hypertonic saline b. postural drainage with percussion c. prepare for NG tube placement d. avoid catheterization e. cool humidified air f. prepare for chest tube placement

f A chest tube will be used to pull air and any fluid out of the pleural space. This allows for the lung to re-expand and attach back to the chest wall.

Picmonic - pneumothorax 4. When caring for a patient with a pneumothorax, which of the following is most likely a consideration? a. DOT b. fat soluble vitamin supplements c. BCG vaccination d. identify triggers e. lowest O2 therapy f. Educate high risk patients

f Educate high risk patients about the risk of developing a pneumothorax. Invasive procedures such as thoracentesis or lung surgical procedure can result in the pleural space being compromised. Chronic lung illnesses like Cystic Fibrosis, COPD, Emphysema, lung cancer, or patient requiring mechanical ventilation are also at risk for developing a spontaneous or tension pneumothorax.

Picmonic - Flail Chest 6. Which of the following is most likely indicated in Flail Chest? a. dental procedures b. surgical repair c. NPO with NG tube to suction d. prepare for chest tube placement e. elevate HOB f. intercostal nerve blocks

f Intercostal nerve blocks, and epidural or intrathecal analgesia, are highly recommended for effective pain management in patients with flail chest.

Picmonic - Flail Chest 4. Which of the following is most likely indicated in Flail Chest? a. seizure precautions b. remove or loosen restrictive items c. dexamethasone d. ERCP e. skeletal survey f. mechanical ventilation

f Intubation and mechanical ventilation may be necessary for some patients, in an effort to reestablish lung expansion and to ensure adequate ventilation and oxygenation. Bag-valve-mask ventilation should be performed using 100% oxygen.

Picmonic - chest tube 7. When there is no oscillation in the water chamber, what should you check the suction system for? a. Excessive suction b. Air leak c. Impaired oxygenation d. Inadequate suction e. contamination f. kinking

f The water in the water seal chamber should oscillate; specifically, the level will move up during inhalation and move down during exhalation. When there is no oscillation in the chamber, check the line for kinks.