Med Surg Prep U ch. 21

A client in the intensive care unit has a tracheostomy with humidified oxygen being instilled through it. The client is expectorating thick yellow mucus through the tracheostomy tube frequently. The nurse

15 mins

Which range of water pressure within the endotracheal tube cuff is believed to prevent both injury and aspiration?

15-20

The nurse is caring for a client following a thoracotomy. Which finding requires immediate intervention by the nurse?

190ml

Which is a correct endotracheal tube cuff pressure?

22

A client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for:

5-20

A client has a sucking stab wound to the chest. Which action should the nurse take first?

Apply a dressing over the wound and tape it on three sides.

The nurse should monitor a client receiving mechanical ventilation for which of the following complications?

GI hemorrhage

Which oxygen administration device has the advantage of providing a high oxygen concentration?

Non rebreathing mask

The nurse is teaching a client the proper technique for diaphragmatic breathing. Place the steps for this procedure in the correct sequence.

Place one hand on the abdomen and the other hand on the middle of the chest to increase awareness of the position of the diaphragm and its function in breathing. Breathe in slowly and deeply through the nose, letting the abdomen protrude as far as possible. Breathe out through pursed lips while tightening the abdominal muscles. Press firmly inward and upward on the abdomen while breathing out. Repeat for 1 minute; follow with a 2-minute rest period.

A nurse is caring for a client who was intubated because of respiratory failure. The client is now receiving mechanical ventilation with a preset tidal volume and number of breaths each minute. The client has the ability to breathe spontaneously between the ventilator breaths with no ventilator assistance. The nurse should document the ventilator setting as:

SIMV

The nurse is teaching a postoperative client who had a coronary artery bypass graft about using the incentive spirometer. The nurse instructs the client to perform the exercise in the following order:

Sit in an upright position. Place the mouthpiece of the spirometer in the mouth. Breathe air in through the mouth. Hold breath for about 3 seconds. Exhale air slowly through the mouth.

A client with COPD has been receiving oxygen therapy for an extended period. What symptoms would be indicators that the client is experiencing oxygen toxicity? Select all that apply.

Substernal pain Dyspnea Fatigue

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes?

Water seal chamber

Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. This therapy may be used for a client with:

a compromised skin graft.

The nurse is preparing to assist the health care provider to remove a client's chest tube. Which instruction will the nurse correctly give to the client?

bear down

A client with supraglottic cancer undergoes a partial laryngectomy. Postoperatively, a cuffed tracheostomy tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to:

cough

The nurse hears the patient's ventilator alarm sound and attempts to find the cause. What is the priority action of the nurse when the cause of the alarm is not able to be determined?

dicont and mechanical vent until problem solved

After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must:

encourage cough and deep breath

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation?

endotracheal suctioning

Which range of water pressure within the endotracheal tube cuff is believed to prevent both injury and aspiration?

expect cough

A nurse is caring for a client who has a tracheostomy tube and who is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by:

minimal leak

he nurse is assessing a patient with chest tubes connected to a drainage system. What should the first action be when the nurse observes excessive bubbling in the water seal chamber?

notify physician

A patient is to receive an oxygen concentration of 70%. What is the best way for the nurse to deliver this concentration?

partial rebreather

The nurse is caring for a client who is scheduled for a lobectomy. Following the procedure, the nurse will plan care based on the client

returning to the nursing unit with two chest tubes.

A client undergoes a tracheostomy after many failed attempts at weaning him from a mechanical ventilator. Two days after tracheostomy, while the client is being weaned, the nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first?

suction

A client is prescribed postural drainage because secretions are accumulating in the upper lobes of the lungs. The nurse instructs the client to:

take prescribed albuterol (Ventolin) before performing postural drainage.

client is being mechanically ventilated in the ICU. The ventilator alarms begin to sound. The nurse should complete which action first?

troubleshoot