Chapter 21
Ans: Maintaining a patent airway Feedback: Maintaining a patent (open) airway is achieved through meticulous airway management
A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this patient is necessary. What is the main rationale for this? A) Maintaining a patent airway B) Preventing the need for suctioning C) Maintaining the sterility of the patient's airway D) Increasing the patient's lung compliance Ans:
Ans: Post thoracotomy, Spontaneous pneumothorax, Spontaneous pneumothorax Feedback: Chest drainage systems are used in treatment of spontaneous pneumothorax and trauma resulting in pneumothorax.
A nurse educator is reviewing the indications for chest drainage systems with a group of medical nurses. What indications should the nurses identify? Select all that apply. A) Post thoracotomy B) Spontaneous pneumothorax C) Need for postural drainage D) Chest trauma resulting in pneumothorax E) Pleurisy
Ans: Measure the patient's oxygen saturation. Feedback: The patient's response to suctioning is usually determined by performing chest auscultation and by measuring the patient's oxygen saturation.
A nurse has performed tracheal suctioning on a patient who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention? A) Determine whether the patient can now perform forced expiratory technique (FET). B) Percuss the patient's lungs and thorax. C) Measure the patient's oxygen saturation. D) Have the patient perform incentive spirometry.
Ans: Removing excess air and fluid Feedback: Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood.
A nurse is educating a patient in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the patient and the family that this drainage system is used for? A) Maintaining positive chest-wall pressure B) Monitoring pleural fluid osmolarity C) Providing positive intrathoracic pressure D) Removing excess air and fluid
Ans: "Breathe in deeply through the spirometer, hold your breath briefly, and then exhale." Feedback: The patient should be taught to lace the mouthpiece of the spirometer firmly in the mouth, breathe air in through the mouth, and hold the breath
A nurse is teaching a patient how to perform flow type incentive spirometry prior to his scheduled thoracic surgery. What instruction should the nurse provide to the patient? A) "Hold the spirometer at your lips and breathe in and out like you normally would." B) "When you're ready, blow hard into the spirometer for as long as you can." C) "Take a deep breath and then blow short, forceful breaths into the spirometer." D) "Breathe in deeply through the spirometer, hold your breath briefly, and then exhale."
Ans: Provide emotional support to the patient and family. Feedback: The recovery process may take longer than the patient had expected, and providing support to the patient is an important task for the home care nurse.
A patient has been discharged home after thoracic surgery. The home care nurse performs the initial visit and finds the patient discouraged and saddened. The client states, "I am recovering so slowly. I really thought I would be better by now." What nursing action should the nurse prioritize? A) Provide emotional support to the patient and family. B) Schedule a visit to the patient's primary physician within 24 hours. C) Notify the physician that the patient needs a referral to a psychiatrist. D) Place a referral for a social worker to visit the patient.
Ans: "When an endotracheal tube is left in too long it can damage the lining of the windpipe." Feedback: Endotracheal intubation may be used for no longer than 2 to 3 weeks, trauma to, the tracheal lining, to reduce the incidence of vocal cord paralysis (secondary to laryngeal nerve damage), and to decrease the work of breathing.
A patient in the ICU has had an endotracheal tube in place for 3 weeks. The physician has ordered that a tracheostomy tube be placed. The patient's family wants to know why the endotracheal tube cannot be left in place. What would be the nurse's best response? A) "The physician may feel that mechanical ventilation will have to be used long-term." B) "Long-term use of an endotracheal tube diminishes the normal breathing reflex." C) "When an endotracheal tube is left in too long it can damage the lining of the windpipe." D) "It is much harder to breathe through an endotracheal tube than a tracheostomy."
Ans: Correct use of incentive spirometry Feedback: Instruction in the use of incentive spirometry begins before surgery to familiarize the patient with its correct use.
A patient is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching includes what? A) Correct use of a ventilator B) Correct use of incentive spirometry C) Correct use of a mini-nebulizer D) Correct technique for rhythmic breathing
Ans: To remove air from the pleural space Feedback: Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. T
A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube? A) To remove air from the pleural space B) To drain copious sputum secretions C) To monitor bleeding around the lungs D) To assist with mechanical ventilation
Ans: Express empathy and then encourage the patient to write, use a picture board, or spell words with an alphabet board. Feedback: If the patient uses an alternative method of communication, he will feel in better control and likely be less frustrated.
A patient recovering from thoracic surgery is on long-term mechanical ventilation and becomes very frustrated when he tries to communicate. What intervention should the nurse perform to assist the patient? A) Assure the patient that everything will be all right and that remaining calm is the best strategy. B) Ask a family member to interpret what the patient is trying to communicate. C) Ask the physician to wean the patient off the mechanical ventilator to allow the patient to speak freely. D) Express empathy and then encourage the patient to write, use a picture board, or spell words with an alphabet board.
Ans: Venturi mask Feedback: The Venturi mask provides the most accurate method of oxygen delivery.
A patient with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the physician to order? A) Non-rebreather air mask B) Tracheostomy collar C) Venturi mask D) Face tent
Ans: Assist the patient into a position that will allow gravity to move secretions. Feedback: The patient uses gravity to facilitate postural draining.
A patient's plan of care specifies postural drainage. What action should the nurse perform when providing this noninvasive therapy? A) Administer the treatment with the patient in a high Fowler's or semi-Fowler's position. B) Perform the procedure immediately following the patient's meals. C) Apply percussion firmly to bare skin to facilitate drainage. D) Assist the patient into a position that will allow gravity to move secretions.
Ans: Chest auscultation Feedback: Chest auscultation should be performed before and after postural drainage in order to evaluate the effectiveness of the therapy.
Postural drainage has been ordered for a patient who is having difficulty mobilizing her bronchial secretions. Before repositioning the patient and beginning treatment, the nurse should perform what health assessment? A) Chest auscultation B) Pulmonary function testing C) Chest percussion D) Thoracic palpation
Ans: 20 cm H2O Feedback: The amount of suction is determined by the water level. It is usually set at 20 cm H2O; adding more fluid results in more suction.
The OR nurse is setting up a water-seal chest drainage system for a patient who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system? A) 20 cm H2O B) 15 cm H2O C) 10 cm H2O D) 5 cm H2O
Ans: Baseline arterial blood gas (ABG) levels Feedback: Before weaning a patient from mechanical ventilation, it is most important to have baseline ABG levels.
The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess? A) Fluid intake for the last 24 hours B) Baseline arterial blood gas (ABG) levels C) Prior outcomes of weaning D) Electrocardiogram (ECG) results
Ans: Stable vital signs and ABGs Feedback: Among many other predictors, stable vital signs and ABGs are important predictors of successful weaning.
The critical care nurse and the other members of the care team are assessing the patient to see if he is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify? A) Stable vital signs and ABGs B) Pulse oximetry above 80% and stable vital signs C) Stable nutritional status and ABGs D) Normal orientation and level of consciousness
Ans: Monitor the pressure in the cuff at least every 8 hours Feedback: Cuff pressure must be monitored by the respiratory therapist or nurse at least every 8 hours by attaching a handheld pressure gauge to the pilot balloon of the tube or by using the minimal leak volume or minimal occlusion volume technique.
The critical care nurse is precepting a new nurse on the unit. Together they are caring for a patient who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff? A) Deflate the cuff overnight to prevent tracheal tissue trauma. B) Inflate the cuff to the highest possible pressure in order to prevent aspiration. C) Monitor the pressure in the cuff at least every 8 hours D) Keep the tracheostomy tube plugged at all times.
Ans: Signs of pulmonary infection Feedback: The nurse teaches the patient and family about the ventilator, suctioning, tracheostomy care, signs of pulmonary infection, cuff inflation and deflation, and assessment of vital signs.
The decision has been made to discharge a ventilator-dependent patient home. The nurse is developing a teaching plan for this patient and his family. What would be most important to include in this teaching plan? A) Administration of inhaled corticosteroids B) Assessment of neurologic status C) Turning and coughing D) Signs of pulmonary infection Ans:
Ans: The patient desires a portable oxygen delivery system that can deliver 2 L/min. Feedback: The patient desiring a portable oxygen delivery system of 2L/min will benefit from the use of an oxygen concentrator.
The home care nurse is assessing a patient who requires home oxygen therapy. What criterion indicates that an oxygen concentrator will best meet the needs of the patient in the home environment? A) The patient desires a low-maintenance oxygen delivery system that delivers oxygen flow rates up to 6 L/min. B) The patient requires a high-flow system for use with a tracheostomy collar. C) The patient desires a portable oxygen delivery system that can deliver 2 L/min. D) The patient's respiratory status requires a system that provides an FiO2 of 65%.
Ans: COPD Feedback: Breathing retraining is especially indicated in patients with COPD and dyspnea.
The home care nurse is planning to begin breathing retraining exercises with a client newly admitted to the home health service. The home care nurse knows that breathing retraining is especially indicated if the patient has what diagnosis? A) Asthma B) Pneumonia C) Lung cancer D) COPD
Ans: Signs and symptoms of respiratory complications Feedback: The nurse assesses the patient's adherence to the postoperative treatment plan and identifies acute or late postoperative complications.
The home care nurse is visiting a patient newly discharged home after a lobectomy. What would be most important for the home care nurse to assess? A) Resumption of the patient's ADLs B) The family's willingness to care for the patient C) Nutritional status and fluid balance D) Signs and symptoms of respiratory complications
Ans: Monitor cuff pressure every 8 hours. Feedback: The cuff pressure should be monitored every 8 hours. It is important to perform tracheostomy care at least every 8 hours because of the risk of infection. The patient should be encouraged to ambulate, i
The medical nurse is creating the care plan of an adult patient requiring mechanical ventilation. What nursing action is most appropriate? A) Keep the patient in a low Fowler's position. B) Perform tracheostomy care at least once per day. C) Maintain continuous bedrest. D) Monitor cuff pressure every 8 hours.
Ans: The cough reflex is depressed. Feedback: Disadvantages include suppression of the patient's cough reflex, thickening of secretions, and depressed swallowing reflexes. bleeding is not an expected finding. The tube should not influence cognition and daily ABGs are not always required.
The nurse caring for a patient with an endotracheal tube recognizes several disadvantages of an endotracheal tube. What would the nurse recognize as a disadvantage of endotracheal tubes? A) Cognition is decreased. B) Daily arterial blood gases (ABGs) are necessary. C) Slight tracheal bleeding is anticipated. D) The cough reflex is depressed.
Ans: Pulmonary function studies Feedback: Pulmonary function studies are performed to determine whether the planned resection will leave sufficient functioning lung tissue. ABG values are assessed to provide a more complete picture of the functional capacity of the lung. Exercise tolerance tests are useful to determine if the patient who is a candidate for pneumonectomy can tolerate removal of one of the lungs. Preoperative studies, such as a chest x-ray, are performed to provide a baseline for comparison during the postoperative period and to detect any unsuspected abnormalities.
The nurse has admitted a patient who is scheduled for a thoracic resection. The nurse is providing preoperative teaching and is discussing several diagnostic studies that will be required prior to surgery. Which study will be performed to determine whether the planned resection will leave sufficient functioning lung tissue? A) Pulmonary function studies B) Exercise tolerance tests C) Arterial blood gas values D) Chest x-ray
Ans: Teach him how to perform huffing. Feedback: The technique of "huffing" may be helpful for the patient with diminished expiratory flow rates or for the patient who refuses to cough because of severe pain.
The nurse has explained to the patient that after his thoracotomy, it will be important to adhere to a coughing schedule. The patient is concerned about being in too much pain to be able to cough. What would be an appropriate nursing intervention for this client? A) Teach him postural drainage. B) Teach him how to perform huffing. C) Teach him to use a mini-nebulizer. D) Teach him how to use a metered dose inhaler.
Ans: Document that the chest drainage system is operating as it is intended. Feedback: Fluctuation of the water level in the water seal shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent.
The nurse is assessing a patient who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the patient's respirations. How should the nurse best respond to this assessment finding? A) Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes. B) Inform the physician promptly that there is in imminent leak in the drainage system. C) Encourage the patient to do deep breathing and coughing exercises. D) Document that the chest drainage system is operating as it is intended.
Ans: Between 15 and 20 mm Hg Feedback: Complications can occur from pressure exerted by the cuff on the tracheal wall. Cuff pressures should be maintained between 15 and 20 mm Hg.
The nurse is caring for a client with an endotracheal tube who is on a ventilator. When assessing the client, the nurse knows to maintain what cuff pressure to maintain appropriate pressure on the tracheal wall? A) Between 10 and 15 mm Hg B) Between 15 and 20 mm Hg C) Between 20 and 25 mm Hg D) Between 25 and 30 mm Hg
Ans: Nasal cannula Feedback: A nasal cannula is used when the patient requires a low to medium concentration of oxygen for which precise accuracy is not essential.
The nurse is caring for a patient who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. What method of oxygen delivery is most appropriate for the patient's needs? A) Non-rebreathing mask B) Nasal cannula C) Simple mask D) Partial-rebreathing mask
Ans: Removal from the ventilator, tube, and then oxygen Feedback: The process of withdrawing the patient from dependence on the ventilator takes place in three stages: the patient is gradually removed from the ventilator, then from the tube, and, finally, oxygen.
The nurse is caring for a patient who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning the patient from a ventilator, the nurse is aware that the weaning of the patient will progress in what order? A) Removal from the ventilator, tube, and then oxygen B) Removal from oxygen, ventilator, and then tube C) Removal of the tube, oxygen, and then ventilator D) Removal from oxygen, tube, and then ventilator
Ans: How to splint the incision when coughing Feedback: Prior to thoracotomy, the nurse educates the patient about how to splint the incision with the hands, a pillow, or a folded towel.
The nurse is caring for a patient who is scheduled to have a thoracotomy. When planning preoperative teaching, what information should the nurse communicate to the patient? A) How to milk the chest tubing B) How to splint the incision when coughing C) How to take prophylactic antibiotics correctly D) How to manage the need for fluid restriction
Ans: Dyspnea and substernal pain Feedback: Oxygen toxicity can occur when patients receive too high a concentration of oxygen for an extended period. Symptoms of oxygen toxicity include dyspnea, substernal pain, restlessness, fatigue, and progressive respiratory difficulty.
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient has been receiving high-flow oxygen therapy for an extended time. What symptoms should the nurse anticipate if the patient were experiencing oxygen toxicity? A) Bradycardia and frontal headache B) Dyspnea and substernal pain C) Peripheral cyanosis and restlessness D) Hypotension and tachycardia
Ans: Perform shoulder exercises five times daily. Feedback: The nurse emphasizes the importance of progressively increased activity.
The nurse is discussing activity management with a patient who is postoperative following thoracotomy. What instructions should the nurse give to the patient regarding activity immediately following discharge? A) Walk 1 mile 3 to 4 times a week. B) Use weights daily to increase arm strength. C) Walk on a treadmill 30 minutes daily. D) Perform shoulder exercises five times daily.
Ans: Wait several minutes and then repeat suctioning. Feedback: If additional suctioning is needed, the nurse should withdraw the catheter to the back of the pharynx, reassure the patient, and oxygenate for several minutes before resuming suctioning.
The nurse is performing nasotracheal suctioning on a medical patient and obtains copious amounts of secretions from the patient's airway, even after inserting and withdrawing the catheter several times. How should the nurse proceed? A) Continue suctioning the patient until no more secretions are obtained. B) Perform chest physiotherapy rather than nasotracheal suctioning. C) Wait several minutes and then repeat suctioning. D) Perform postural drainage and then repeat suctioning.
Ans: How to perform diaphragmatic breathing Feedback: Diaphragmatic breathing is a helpful technique to prepare for proper use of the small-volume nebulizer.
The nurse is performing patient education for a patient who is being discharged on mini-nebulizer treatments. What information should the nurse prioritize in the patient's discharge teaching? A) How to count her respirations accurately B) How to collect serial sputum samples C) How to independently wean herself from treatment D) How to perform diaphragmatic breathing
Ans: Correct and safe use of oxygen therapy equipment Feedback: Therefore, the nurse needs to instruct the patient and family in their correct and safe use. .
The nurse is preparing to discharge a patient after thoracotomy. The patient is going home on oxygen therapy and requires wound care. As a result, he will receive home care nursing. What should the nurse include in discharge teaching for this patient? A) Safe technique for self-suctioning of secretions B) Technique for performing postural drainage C) Correct and safe use of oxygen therapy equipment D) How to provide safe and effective tracheostomy care
Ans: Assess the patient's lung sounds and SAO2 via pulse oximeter. Feedback: Assessment data indicate the need for suctioning and allow the nurse to monitor the effect of suction on the patient's level of oxygenation.
The nurse is preparing to suction a patient with an endotracheal tube. What should be the nurse's first step in the suctioning process? A) Explain the suctioning procedure to the patient and reposition the patient. B) Turn on suction source at a pressure not exceeding 120 mm Hg. C) Assess the patient's lung sounds and SAO2 via pulse oximeter. D) Perform hand hygiene and don nonsterile gloves, goggles, gown, and mask.
Ans: CPAP allows a lower percentage of oxygen to be used with a similar effect. Feedback: Prevention of oxygen toxicity is achieved by using oxygen only as prescribed. Often, positive end-expiratory pressure (PEEP) or CPAP is used with oxygen therapy to reverse or prevent microatelectasis, thus allowing a lower percentage of oxygen to be used.
The physician has ordered continuous positive airway pressure (CPAP) with the delivery of a patient's high-flow oxygen therapy. The patient asks the nurse what the benefit of CPAP is. What would be the nurse's best response? A) CPAP allows a higher percentage of oxygen to be safely used. B) CPAP allows a lower percentage of oxygen to be used with a similar effect. C) CPAP allows for greater humidification of the oxygen that is administered. D) CPAP allows for the elimination of bacterial growth in oxygen delivery systems.
Ans: A patient requires permanent ventilation. Feedback: A tracheostomy permits long-term use of mechanical ventilation to prevent aspiration of oral and gastric secretions in the unconscious or paralyzed patient.
What would the critical care nurse recognize as a condition that may indicate a patient's need to have a tracheostomy? A) A patient has a respiratory rate of 10 breaths per minute. B) A patient requires permanent ventilation. C) A patient exhibits symptoms of dyspnea. D) A patient has respiratory acidosis.
Ans: The system has an air leak. Feedback: Constant bubbling in the chamber often indicates an air leak and requires immediate assessment and intervention. The patient with a pneumothorax will have intermittent bubbling in the water-seal chamber.
While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of the patient's closed chest-drainage system. What should the nurse conclude? A) The system is functioning normally. B) The patient has a pneumothorax. C) The system has an air leak. D) The chest tube is obstructed.
Ans: When adventitious breath sounds are auscultated Feedback: Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are present. Unnecessary suctioning, such as scheduling every 2 hours, can initiate bronchospasm
While caring for a patient with an endotracheal tube, the nurses recognizes that suctioning is required how often? A) Every 2 hours when the patient is awake B) When adventitious breath sounds are auscultated C) When there is a need to prevent the patient from coughing D) When the nurse needs to stimulate the cough reflex