Oxygenation Study Guide Q&A
Which postprocedure vital sign schedule meets the minimum needs of your patient? a. Every 15 minutes for the first 2 hours b. Every 10 minutes for the first hour c. Every 15 minutes for the first hour, then every 30 minutes for the next hour, and then every hour for the next 4 hours d. Every 15 minutes times 2, then every hour times 4, and then every 4 hours
a. Every 15 minutes for the first 2 hours
Which of the following can cause a tension pneumothorax? (Select all that apply. a. Kinked chest tube b. Clamped chest tube c. Obstructed by a blood clot d. Suction source set too high e. Absence of water in the water-seal compartment f. Use of a mechanical ventilator for respiratory support g. Waterless drainage system knocked over
a. Kinked chest tube b. Clamped chest tube c. Obstructed by a blood clot e. Absence of water in the water-seal compartment
Which suctioning techniques can be delegated to trained and competent NAP and/or patients and their families when the patient is stable? (Select all that apply.) a. Oropharyngeal. b. Nasotracheal. c. Open tracheostomy. d. Open endotracheal. e. Inline endotracheal.
a. Oropharyngeal c. Open tracheostomy.
The patient is anxious about having his chest tube removed. He states, "I'm afraid my lung will just collapse again. Is there anything I can do to help?" The nurse's best response is: . "Yes, you should take a deep breath and hold it while the chest tube is being removed. We will tell you when." a. "There is no reason to worry. That rarely happens, and if it does, the doctor will just insert a new chest tube." b. "Yes, you can lie very still and focus on taking normal breaths while the physician removes the chest tube." c. "There's nothing you can do to help that from occurring, so you might as well relax. I'm sure you'll be just fine."
. "Yes, you should take a deep breath and hold it while the chest tube is being removed. We will tell you when."
A patient has clear oral secretions that are extremely copious and thick. What would be an appropriate response by the nurse? a. Oropharyngeal suctioning. b. Nasopharyngeal suctioning. c. Nasotracheal suctioning. d. Obtain a sputum specimen for culture and sensitivity.
a. Oropharyngeal suctioning
When is a tension pneumothorax?
A tension pneumothorax occurs when air enters the pleural space but cannot escape via the route of entry. The increased positive pressure in the pleural space results in the collapse of lung tissue. If left untreated, this pressure builds up, causing a complete collapse of the lung. In addition, the contents of the mediastinum shift, and the pressure from these contents places pressure on the heart and great vessels, such as the vena cava. In turn, this pressure results in a decreased venous return and subsequent cardiac output.
Describe the huff cough.
A huff cough stimulates the natural cough reflex. It is helpful in clearing the large central airways.
Which of the following is an expected finding for a chest tube located in the 6th lateral intercostal space? a. Over time, the volume of drainage decreases, and the color changes from red to serous. b. Over time, the volume of drainage increases, and the color remains the same. c. Over time, the volume of drainage remains the same, and the color changes from serous to red. d. There is no drainage; only air escapes the pleural space.
a. Over time, the volume of drainage decreases, and the color changes from red to serous.
You are busy performing routine assessments of the patients on the unit. You note audible gurgling on inspiration and expiration of the stable postoperative patient. Which of the following tasks can you delegate to competent NAP? a. Performing oral suctioning b. Assessing the adequacy of respiratory functioning c. Evaluating the outcome of oral suctioning d. Performing nasotracheal suctioning
a. Performing oral suctioning
What type of cough that would be recommended? A patient with a large amount of sputum.
Cascade cough
What type of cough that would be recommended? A patient who has a spinal cord injury.
Huff cough
The nurse is preparing to perform routine tracheostomy care. Which statements, if made by the nurse, indicate that further instruction is needed? (Select all that apply.) a. "I will drop the inner cannula into a sterile basin of normal saline." b. "After I secure the ends of the tracheostomy ties, I should be able to fit one finger loosely or two fingers snugly under the ties." c. "I will double knot the ties behind the patient's neck." d. "I should clean the tracheostomy stoma in a circular motion from the stoma site moving outward approximately 2 to 4 inches." e. "After I clean the inner cannula and replace it, I may use the brush to clean around the stoma."
a. "I will drop the inner cannula into a sterile basin of normal saline." c. "I will double knot the ties behind the patient's neck." e. "After I clean the inner cannula and replace it, I may use the brush to clean around the stoma."
What should the nurse monitor in order to evaluate the presence of a possible complication of closed inline suctioning? a. Pulse oximetry. b. Presence of gag reflex. c. Peripheral edema. d. History of allergies.
a. Pulse oximetry.
What type of cough that would be recommended? A patient who is 2 days post-op from abdominal surgery or a patient who is paralyzed.
Quad cough
Describe the quad cough.
The quad cough is used with patients who lack control of their abdominal muscles. As the patient is breathing out with as much force as possible, you push inward and upward on the abdominal muscles in the direction of the diaphragm.
Describe the cascade cough.
To perform a cascade cough, the patient inhales and holds the breath for 2 seconds, then coughs during expiration. This technique promotes airway clearance in patients with large volumes of sputum.
You are taking care of a patient with inline closed suctioning of an endotracheal tube. The nursing instructor realizes that you require further teaching when you state: (Select all that apply.) a. "I will suction the patient as I insert the catheter upon inhalation." b. "If I have difficulty obtaining secretions, I should turn the suction level higher." c. "If the patient coughs, I should stop suctioning." d. "I should allow the patient to rest 1 to 2 minutes and reoxygenate in between suction passes." e. "Suctioning can cause complications such as dysrhythmias, hypoxia, and bronchospasm." f. "I should assess my patient's lung sounds and pulse oximetry before and after suctioning."
a. "I will suction the patient as I insert the catheter upon inhalation." b. "If I have difficulty obtaining secretions, I should turn the suction level higher." c. "If the patient coughs, I should stop suctioning."
The nurse is orienting a newly hired nurse to a surgical intensive care unit. The newly hired nurse asks when endotracheal tube care is necessary. The correct response is: a. "Signs that endotracheal tube care must be performed include loosening of the tapes, soiled tapes, mobility of the tube, and alteration in skin or tissue integrity." b. "When the patient begins to cough continuously." c. "It should be done at least every 8 to 12 hours." d. "Indications for endotracheal tube care include wheezes, crackles, audible gurgling, secretions in the mouth, decreased pulse oximetry, tachypnea, and tachycardia."
a. "Signs that endotracheal tube care must be performed include loosening of the tapes, soiled tapes, mobility of the tube, and alteration in skin or tissue integrity."
A nursing student is helping care for a patient with a chest tube. The nursing student asks you ( the staff nurse) what determines the level of suction in the chest tube. What is your correct response? (Select all that apply.) a. "The depth of fluid in the suction control chamber of a water-seal system determines the highest amount of negative pressure that can be present within the system." b. "The setting of the wall suction determines the amount of negative pressure present within the water-seal system." c. "The suction float ball indicates the amount of suction the patient's intrapleural space is receiving in a waterless system." d. "Whether it is a two-chamber or three-chamber system determines the level of suction. Three-chamber systems have more area to collect drainage, creating a greater negative intrapleural pressure."
a. "The depth of fluid in the suction control chamber of a water-seal system determines the highest amount of negative pressure that can be present within the system." c. "The suction float ball indicates the amount of suction the patient's intrapleural space is receiving in a waterless system."
A discussion is taking place on the unit regarding the application of lubricant to the suction catheter before passing it through the nasal passage. Which statement is accurate? a. "Water-soluble lubricant should be used because oil based lubricants increase the risk for aspiration and pneumonia." b. "If the patient's fluid status is sufficient, lubricating the catheter is unnecessary." c. "Petroleum jelly can be used to lubricate the catheter as long as the patient is not on oxygen via nasal cannula." d. "Applying water-soluble lubricant to the suction catheter ensures that it is working properly prior to oropharyngeal or nasotracheal suctioning."
a. "Water-soluble lubricant should be used because oil based lubricants increase the risk for aspiration and pneumonia."
A patient's family member asks what causes the patient's lung to collapse. The nurse's best response is a. "When the intactness of the pleural space is broken, the space fills with air and/or fluid, causing positive thoracic pressure, which collapses lung tissue." b. "The exact cause remains unknown, but it is thought a collapsed lung may occur as a result of a weakened diaphragm." c. "Several factors can cause a lung to collapse, such as an increase in fibrous lung tissue, especially in the patient who smokes." d. "The negative pressure between the parietal pleura and the visceral pleura becomes too great."
a. "When the intactness of the pleural space is broken, the space fills with air and/or fluid, causing positive thoracic pressure, which collapses lung tissue."
Which of the following would lead to an increase in oxygen demand? a. A fever b. Sleep c. Taking a narcotic d. Postural drainage
a. A fever
Which of the following is a potential complication for a patient who is having nasotracheal suctioning? (Select all that apply.) a. A significant drop in oxygen concentration. b. A decrease in heart rate. c. Dysrhythmias. d. Coughing during and after suctioning.
a. A significant drop in oxygen concentration. b. A decrease in heart rate. c. Dysrhythmias.
Which of the following is an unexpected outcome during or after endotracheal suctioning and endotracheal tube care? a. A sudden drop in oxygen saturation. b. Depth of tube is the same as when started or as ordered (same centimeter marking at gums or lips). c. Clean tape is firmly secured to cheeks, upper lip, top of nose, and tube only. d. Bilateral breath sounds are equal.
a. A sudden drop in oxygen saturation.
Which of the following are indications a patient is ready to have his chest tube removed? (Select all that apply.) a. Absence of tidaling for 24 hours b. Absence of water in the water-seal compartment c. Vital signs within normal limits d. Drainage is serous in color e. Less than 50 mL of drainage in 24 hours f. Absence of bubbles in water-seal compartment g. Resonance on percussion of lungs
a. Absence of tidaling for 24 hours e. Less than 50 mL of drainage in 24 hours g. Resonance on percussion of lungs
An elderly woman is hospitalized with pneumonia and anemia. She is weak and has a poor cough effort. She has a history of cardiomyopathy. Her current vital signs are temperature 100.2 °F, pulse 114, respiration 26, blood pressure 106/58. She has oxygen ordered at 2 liters by nasal cannula. Her oxygen saturation measures 88% when on room air, 93% with supplemental oxygen. She develops shortness of breath on any activity and eats little because it is difficult for her to eat and breathe at the same time. Which of the following are risk factors for this patient developing hypoxia? (Select all that apply.) a. Anemia b. Tachycardia c. Increased secretions with weak cough d. Cardiomyopathy e. Shortness of breath f. Pneumonia
a. Anemia c. Increased secretions with weak cough d. Cardiomyopathy f. Pneumonia
A patient has just had a chest tube removed. Prior to the procedure the patient received pain medication. The patient's vital signs at the time were as follows: BP 120/80, pulse rate 76, respiratory rate 20, pulse oximetry 95%, and temperature 98.1° F. The nurse reassesses the patient postprocedure. Which of the following would require notifying the physician? a. BP 100/60, pulse rate 96, respiratory rate 30, and pulse oximetry 90%. b. The patient exhibits facial grimacing and may require an additional dose of pain medication. c. It is standard procedure to notify the physician of vital sign results regardless of their reading. d. BP126/84, pulse rate 72, respiratory rate 16, pulse oximetry 95% and temperature 98.2° F.
a. BP 100/60, pulse rate 96, respiratory rate 30, and pulse oximetry 90%.
The nurse is concerned the patient is developing atelectasis as a result of immobility. Crackles are noted upon auscultation. Which type of coughing technique is best for the nurse to teach the patient? a. Cascade. b. Huff. c. Quad. d. Chest percussion.
a. Cascade
Which of the following is an accurate reflection of closed inline suctioning? (Select all that apply.) a. Closed inline suctioning systems are sterile. b. Sterile gloves are worn for closed inline suctioning. c. There is less risk of oxygen desaturation with closed inline suctioning than with open suctioning. d. Closed inline suction devices increase the risk for infection.
a. Closed inline suctioning systems are sterile. c. There is less risk of oxygen desaturation with closed inline suctioning than with open suctioning.
The nurse is monitoring the functioning of a three-chamber, water-seal drainage system. Which of the following would negatively affect the functioning of this type of chest tube drainage system? (Select all that apply.) a. Evaporation in the water-seal chamber b. Evaporation in the suction control chamber c. Evaporation in the collection chamber d. If the drainage system is tipped over
a. Evaporation in the water-seal chamber b. Evaporation in the suction control chamber d. If the drainage system is tipped over
The NAP is interested in becoming a nurse. She has asked if she can be of assistance during the chest tube insertion. What activities can she do related to inserting, maintaining, and removing a chest tube? (Select all that apply.) a. Report patient complaints of discomfort or pain. b. Report that the chest tube is kinked. c. Fix problems with the chest tube. d. Gather equipment for the procedures. e. Position the patient for the procedure. f. Explain the procedure to the patient. g. Provide assistance to the physician during the procedure.
a. Report patient complaints of discomfort or pain. b. Report that the chest tube is kinked. d. Gather equipment for the procedures. e. Position the patient for the procedure.
Which of the following would be an appropriate nursing diagnosis for the patient who has a tracheostomy tube? a. Risk of altered skin integrity. b. Impaired mobility. c. Fluid volume deficit. d. Risk of fluid volume excess.
a. Risk of altered skin integrity.
What clinical signs and symptoms do you expect in a patient who requires chest tube insertion for a pneumothorax? (Select all that apply.) a. Shallow respirations at a rate greater than 20 breaths per minute b. Anxious and restless c. Diaphoretic d. Cyanotic e. Chest pain f. Normal depth of breathing at a rate less than 20 breaths per minute g. Pulse oximetry reading greater than 95%
a. Shallow respirations at a rate greater than 20 breaths per minute b. Anxious and restless c. Diaphoretic d. Cyanotic e. Chest pain
A patient has a chest tube inserted in his left third intercostal space for treatment of a pneumothorax. Which of the following indicates a tension pneumothorax may be developing in the patient? (Select all that apply.) a. Shift of trachea to unaffected side of chest b. Decreased cardiac output c. Tidaling in the water-seal chamber d. Change in color of drainage e. Hypotension f. Tachycardia
a. Shift of trachea to unaffected side of chest b. Decreased cardiac output e. Hypotension f. Tachycardia
Identify the situations that require endotracheal tube care. (Select all that apply.) a. Soiled or loose tape. b. Foul odor of mouth. c. Pressure sore on naris or corner of mouth. d. Breath sounds are equal and endotracheal tube remains at same depth. e. Patient was recently shaved.
a. Soiled or loose tape. b. Foul odor of mouth. c. Pressure sore on naris or corner of mouth.
Choose the symptoms that indicate the need to suction a tracheostomy tube: (Select all that apply.) a. Sonorous wheezing. b. Gurgling. c. Restless/anxious. d. Cyanosis. e. Mucus draining from the tracheostomy tube. f. Pulse oximetry value below 90%. g. Fatigue. h. Posturing.
a. Sonorous wheezing. b. Gurgling. c. Restless/anxious. d. Cyanosis. e. Mucus draining from the tracheostomy tube. f. Pulse oximetry value below 90%.
The nurse is preparing the equipment for removal of a chest tube. Which of the following would be unnecessary for this procedure? a. Sterile suction catheter, sterile normal saline, and sterile basin b. Unopened sterile chest tube tray and unopened chest drainage system c. Suture set, sterile scissors and sterile gloves d. Petrolatum-impregnated gauze, 4 x 4 gauze, large dressing, and tape
a. Sterile suction catheter, sterile normal saline, and sterile basin
The nurse is assisting the physician to insert a chest tube. Which of the following actions, if performed by the nurse, would require correction? (Select all that apply.) a. The nurse hands the non-sterile anesthetic vial to the physician when ready. b. The nurse obtains vital signs before, during and after the procedure. c. Using sterile technique, the nurse holds the drainage tube while the physician connects the chest tube. d. The nurse tapes the connection between the chest tube and the drainage tube with a spiral pattern. e. The nurse coils the tubing on the patient's bed. f. The nurse marks the drainage chamber with the start date and time, the beginning amount of drainage and the nurse's initials.
a. The nurse hands the non-sterile anesthetic vial to the physician when ready. e. The nurse coils the tubing on the patient's bed.
The student nurse is observing the staff nurse perform routine tracheostomy care. Which of the following actions, if made by the staff nurse, would be inappropriate? a. The nurse removes the soiled tracheostomy ties, cleans the flange, and applies new tracheostomy ties, securing them tightly behind the patient's neck. b. The nurse oxygenates the patient, suctions the tracheostomy tube, and removes the soiled tracheostomy dressing before removing gloves. c. The nurse cleans around the tracheostomy faceplate and stoma with hydrogen peroxide, then rinses with normal saline-saturated gauze and cotton-tipped applicators. d. The nurse removes the inner cannula and places it in a sterile basin of hydrogen peroxide to soak.
a. The nurse removes the soiled tracheostomy ties, cleans the flange, and applies new tracheostomy ties, securing them tightly behind the patient's neck.
During your assessment of your patient's record, what items are "red flags" that should be brought to the attention of the physician prior to chest tube insertion? (Select all that apply.) a. The patient has had a stroke and is receiving anticoagulants. b. The patient has arthritis, which is being treated with aspirin. c. Regular antiplatelet agent use. d. Regular caffeine use. e. The patient is a smoker. f. Hemoglobin value of 10 g per dL. g. Consent form lacks a signature.
a. The patient has had a stroke and is receiving anticoagulants. b. The patient has arthritis, which is being treated with aspirin. c. Regular antiplatelet agent use. f. Hemoglobin value of 10 g per dL. g. Consent form lacks a signature.
The primary purpose of an oral airway is: a. To prevent obstruction of the trachea by displacement of the tongue into the oropharynx. b. To provide a route for suctioning the patient. c. To enable the patient to speak. d. To allow the health care professional to inflate or deflate the cuff as needed.
a. To prevent obstruction of the trachea by displacement of the tongue into the oropharynx.
You are caring for a patient who has undergone major abdominal surgery one day ago. The 72-year-old male patient is weak and lethargic because of large doses of medication for pain control. After noting audible gurgling on inspiration and expiration, you complete a respiratory assessment. Which assessment parameters indicate the need for oral suction? (Select all that apply.) a. Unusual restlessness b. Gagging c. Gurgling and adventitious lung sounds d. Evidence of emesis in the mouth e. Persistent coughing f. Persistent complaints of pain g. Weakness and lethargy accompanied by drooling
a. Unusual restlessness b. Gagging c. Gurgling and adventitious lung sounds d. Evidence of emesis in the mouth e. Persistent coughing g. Weakness and lethargy accompanied by drooling
What is one advantage of a tracheostomy tube over an endotracheal tube? a. With a tracheostomy tube, the amount of anatomic dead space is decreased and thereby increases the patient's oxygen levels. b. The fenestration in the tracheostomy tube prevents the aspiration of gastric contents. c. Tracheostomy tubes can be placed by physicians and other specially trained health care personnel (e.g., physician assistants, licensed respiratory personnel, and paramedics). d. Tracheostomy tubes require less suctioning, whereas endotracheal tubes require suctioning every 1-2 hours.
a. With a tracheostomy tube, the amount of anatomic dead space is decreased and thereby increases the patient's oxygen levels.
You perform nasotracheal suctioning. Which of the following is an incorrect sequence for this procedure? a. You apply sterile gloves, pick up the suction catheter with your dominant hand, secure the catheter to the tubing, connect the tubing to the suction machine, and turn the suction on. b. Wearing sterile gloves, you suction a small amount of sterile normal saline from the basin and lightly coat 6 to 8 cm of the catheter with water-soluble lubricant. c. Using your dominant hand, you gently but quickly insert the catheter into the patient's nares and intermittently suction and rotate the catheter while withdrawing the catheter. d. You rinse the catheter and connecting tubing with normal saline and allow the patient to rest 1 to 2 minutes between catheter passes. You encourage the patient to cough, and when suctioning is complete, you appropriately discard used equipment and perform oral care.
a. You apply sterile gloves, pick up the suction catheter with your dominant hand, secure the catheter to the tubing, connect the tubing to the suction machine, and turn the suction on.
The patient's wife asks why the nurse turns the oxygen all the way up before suctioning the patient. The nurse's best response is: a. "It is necessary in order to create the pressure needed to make the suction machine work effectively." b. "Because suctioning will remove oxygen, the flow rate is increased to prevent a decrease in oxygen available to tissues." c. "As secretions are removed, they need to be replaced with oxygen." d. "A high concentration of oxygen stimulates the respiratory center so the patient will continue breathing during the suctioning procedure."
b. "Because suctioning will remove oxygen, the flow rate is increased to prevent a decrease in oxygen available to tissues."
A student is giving a brief review in clinical post-conference on the different types of artificial airways and how to perform open suctioning. Which statement would require correction? a. "Oral airways are frequently used for patients returning from surgery who are able to breathe spontaneously but are not fully awake." b. "You should not hyperoxygenate the patient with a head injury prior to suctioning." c. "Tracheostomy tubes can be used long term or permanently." d. "Pediatric tracheostomy tubes are cuffless."
b. "You should not hyperoxygenate the patient with a head injury prior to suctioning."
Which of the following patients would have the greatest potential for an alteration in respiration? a. A 15 year-old male with a migraine headache. b. A 44 year-old female with anemia. c. A 19 year-old female with diarrhea. d. A 32 year-old male with an ear ache.
b. A 44 year-old female with anemia.
You were changing the patient's tape on his endotracheal tube when he reached up and extubated himself. What actions should you take? (Select all that apply.) a. Run and get help. b. Assess the patient for spontaneous breathing. c. Administer breaths with an Ambu-bag if necessary. d. Put the endotracheal tube back in. e. Put a tongue blade in the patient's mouth. f. Perform oropharyngeal suctioning. g. Apply sterile gloves. h. Remain with the patient and use the call system to obtain assistance.
b. Assess the patient for spontaneous breathing. c. Administer breaths with an Ambu-bag if necessary. h. Remain with the patient and use the call system to obtain assistance.
Which situation can be delegated to NAP in regard to endotracheal tube care? a. Endotracheal care may be delegated to NAP only if the patient is on a ventilator. b. Assisting the nurse during a tape change by holding the endotracheal tube. c. Performing respiratory assessments before and after endotracheal tube care. d. If the tapes are soiled, the NAP may change the tapes.
b. Assisting the nurse during a tape change by holding the endotracheal tube.
The nurse is performing closed inline suctioning of a patient. The nurse's pre-procedure assessment indicated a pulse oximetry reading of 92%, heart rate 90 beats per minute, respirations 20 per minute and crackles and wheezes upon auscultation. After making two suction passes, the nurse determines the patient's pulse oximetry reading is 95%, heart rate is 80 beats per minute, respiratory rate is 20, and lungs are clear upon auscultation. What is the nurse's best action at this time? a. Stop suctioning immediately and administer supplemental oxygen at 100%. b. Clear the inner cannula of secretions with saline, lock the suction mechanism, turn off the suction, remove gloves, perform hand hygiene, and document. c. Allow the patient to rest 1 to 2 minutes before making a third suction pass. d. Consult with the physician regarding the need for an inhaled bronchodilator or to reduce the frequency and duration of suctioning.
b. Clear the inner cannula of secretions with saline, lock the suction mechanism, turn off the suction, remove gloves, perform hand hygiene, and document.
Which of the following would be an inappropriate intervention for the patient who cannot stop coughing while being suctioned? a. Stop suctioning and allow the patient to rest. b. Determine the need for chest physiotherapy. c. Consult with the physician regarding the need for an inhaled bronchodilator. d. Administer supplemental oxygen.
b. Determine the need for chest physiotherapy.
The nurse is caring for a patient with a chest tube for a hemothorax. The nurse notices that when the patient coughs, there is a gush of blood in the drainage system. What action should the nurse take? a. Notify the physician immediately. b. Document the normal findings and continue to monitor. c. Clamp the chest tube because there has been a pressure change. d. Add more water to the suction control chamber to increase suction
b. Document the normal findings and continue to monitor.
What nursing intervention is appropriate for the patient with a large amount of sputum? a. Perform nasotracheal suctioning every hour b. Encourage the patient to cough every hour while awake c. Place the patient on fluid restriction d. Avoid all milk products
b. Encourage the patient to cough every hour while awake
A patient is being prepared for open-heart surgery. Where would you expect the chest tube to be located when the patient returns from surgery? a. In the second or third intercostal space b. In the mediastinum just below the sternum c. In the fifth or sixth intercostal space d. Posteriorly or laterally
b. In the mediastinum just below the sternum
What effect will increasing the wall suction have on a three-chamber, water-seal chest tube drainage system connected to suction? a. It will increase the rate of lung expansion. b. It will create more vigorous bubbling and faster evaporation of water. c. It will increase the frequency of emptying the drainage collection device. d. It will damage lung tissue if the negative pressure is too great.
b. It will create more vigorous bubbling and faster evaporation of water.
Which of the following should NOT be delegated to NAP? a. Oropharyngeal suctioning. b. Nasotracheal suctioning on a stable patient. c. Pulse oximetry. d. Oral care.
b. Nasotracheal suctioning on a stable patient.
A patient has an endotracheal tube inserted orally. When should the nurse expect to perform endotracheal tube care? a. Whenever the patient begins to cough. b. On a routine schedule every 24 to 48 hours to reposition the tube. c. Only when the depth of the tube has changed from its original position (as indicated by a marking at the lip or gum line). d. According to physician orders.
b. On a routine schedule every 24 to 48 hours to reposition the tube.
The nurse and a NAP are working together to care for a group of patients. Which of the following tasks would be most appropriate for the RN delegate to the NAP? a. Administer a pain medication the nurse has prepared 30 minutes prior to chest tube removal. b. Positioning the patient either sitting or lying supine on the side opposite to that where the chest tube is placed. c. Informing the patient to take a deep breath and hold it while the physician removes the chest tube. d. Auscultating the lungs sounds and obtaining vital signs once the chest tube is removed.
b. Positioning the patient either sitting or lying supine on the side opposite to that where the chest tube is placed.
Which of the following can be removed for cleaning, especially if the patient has copious or tenacious secretions? a. The outer cannula of the tracheostomy tube. b. The inner cannula of the tracheostomy tube. c. The obturator. d. The flange.
b. The inner cannula of the tracheostomy tube.
The nurse is caring for a patient with a tracheostomy who has audible gurgling and requests to be suctioned. Assessment prior to suctioning indicates pulse 84, respirations 24, and pulse oximetry 93%. Which of the following is an indication that the nurse should stop suctioning and oxygenate the patient? a. The patient's pulse oximetry decreases to 90%. b. The patient's pulse decreases to 60 beats per minute. c. The patient's pulse rate increases to 100 beats/minute. d. Thick pale yellow secretions are obtained.
b. The patient's pulse decreases to 60 beats per minute.
A patient has returned from the operating room with a chest tube in his sixth intercostal space with orders to connect the patient to wall suction. The patient has a three-chamber, water-seal system. Eight hours later you find the patient complaining of increased chest pain, a respiratory rate of 40 breaths per minute, and a pulse of 110. The water-seal chamber is dry. The patient is in obvious distress. What should you suspect as the primary cause? a. The patient's chest tube has become dislodged. b. There is no water in the water-seal chamber. c. The wall suction is too low. d. The patient is breathing shallowly and avoiding coughing.
b. There is no water in the water-seal chamber.
What is the purpose of having a fenestrated tube in an artificial airway? a. To decrease the likelihood of aspiration of stomach contents. b. To allow a patient to talk. c. To prevent dislodgment. d. To prevent trauma to the trachea.
b. To allow a patient to talk.
The NAP has received permission to observe the physician remove the chest tube. The NAP asks the nurse, "I thought you are never supposed to clamp a chest tube; why did the physician clamp the chest tube?" All of the following are appropriate reasons except: a. To assess the patient's tolerance of tube removal b. To clear the chest tube of fluid and/or air before it is removed c. To determine the condition of collapsed lung tissue is resolved d. To reveal the location of an air leak in the system
b. To clear the chest tube of fluid and/or air before it is removed
Why is it important to be sure the colored indicator line on the catheter is visible in the sheath when suctioning is complete? a. To ensure retained secretions in the catheter do not "drain" into the patient's airway. b. To prevent airway reduction with the presence of the suction catheter. c. To reduce the risk of infection by removing the secretions from the inner lumen. d. To ensure that suctioning of the patient's airway does not occur accidentally.
b. To prevent airway reduction with the presence of the suction catheter.
Which task could be delegated to NAP? a. Nasotracheal suctioning. b. Tracheostomy care of a well-established tracheostomy. c. Closed inline suctioning if a patient is on a mechanical ventilator. d. Endotracheal tube care.
b. Tracheostomy care of a well-established tracheostomy
Which of the following is an inaccurate statement in regard to performing endotracheal tube care? a. Cut first piece of tape approximately 1 to 2 feet (24 to 48 cm) in length; lay adhesive-side-up on table. b. When rotating the endotracheal tube from one side of the mouth to the other, deflate the cuff. c. Have assistant hold tube in place and note the markings on the tube indicating depth of tube insertion before removing old tape. d. To secure the tapes around the tube, place the top side of the torn tape across the patient's upper lip and tightly wrap the lower side around the tube.
b. When rotating the endotracheal tube from one side of the mouth to the other, deflate the cuff.
The nurse is orienting a new graduate nurse to common procedures performed on the unit. Which statement, if made by the graduate nurse, indicates understanding of nasotracheal suctioning? a. "The maximum duration to suction is 20 seconds." b. "The bacterial count in the nasotracheal pathway is higher than in the oral cavity, so whenever possible, you should suction the trachea through the mouth." c. "A 1- to 2- minute interval should be allowed between suctioning passes." d. "Intermittent suction is applied during insertion of the catheter."
c. "A 1- to 2- minute interval should be allowed between suctioning passes."
A nurse is trying to determine whether or not a patient's artificial airway should be suctioned. Which of the following fails to be an indication for suctioning? a. Pulse oximetry 89%. b. Pulmonary secretions. c. 2 hours have elapsed since patient was last suctioned. d. Patient has audible gurgling and appears restless.
c. 2 hours have elapsed since patient was last suctioned.
The nurse is caring for a patient with a chest tube. Which of the following findings would require follow-up with the physician? a. Absence of tidaling with a mediastinal chest tube for 24 hours. b. The waterless chest tube drainage system was accidentally tipped over. c. Absence of tidaling for 24 hours with a chest tube located in the 2nd lateral intercostal space. d. Gentle fluctuations are noted in the diagnostic indicator of the waterless drainage system.
c. Absence of tidaling for 24 hours with a chest tube located in the 2nd lateral intercostal space.
The nurse is looking at the front of a waterless chest drainage system. Which of the following would be cause for concern? a. After 2 to 3 days, tidaling stops. b. Gentle tidaling is present in the diagnostic air-leak indicator. c. Continuous bubbling is present. d. There is approximately 15 mL of fluid in the diagnostic air-leak indicator.
c. Continuous bubbling is present.
For the patient who extubated himself, what is the priority action the nurse should take? a. Apply a sterile dressing to the site. b. Notify the physician. c. Determine whether the patient is breathing spontaneously. d. Medicate the patient for pain and assess for tissue damage.
c. Determine whether the patient is breathing spontaneously.
You have a 36-year-old female patient with severe asthmatic bronchitis after a short course of influenza. The patient was admitted to your unit and intubated with an oral endotracheal tube. She was placed on mechanical ventilation for respiratory support and the instillation of aerosolized medication. Which of the following demonstrates correct understanding of endotracheal tubes? a. Endotracheal tubes are designed for long-term use. b. Endotracheal tubes are fenestrated so that she will be able to talk when she is feeling better. c. Endotracheal tubes for adults are cuffed and must be inflated for mechanical ventilation to be effective. d. The patient with an endotracheal tube will require less attention to airway patency than the patient who is without an endotracheal tube. Correct answer:
c. Endotracheal tubes for adults are cuffed and must be inflated for mechanical ventilation to be effective.
The nurse is preparing to perform nasotracheal suctioning on a patient. Which of the following would be an appropriate nursing action? a. To effectively suction the left main stem bronchus, turn the patient's head to the left. b. When suctioning artificial airways, it is important to apply suction during insertion. c. Hyperoxygenate the patient prior to suctioning and allow 1 to 2 minutes between suction passes. d. For open nasotracheal suctioning, clean gloves are appropriate.
c. Hyperoxygenate the patient prior to suctioning and allow 1 to 2 minutes between suction passes.
What is the increased risk for the patient if the nurse suctions for more than 15 seconds? a. Pulmonary embolus. b. Infection. c. Hypoxia. d. Dehydration.
c. Hypoxia.
The nurse is caring for a patient who has an endotracheal tube inserted orally. The nurse instructs the NAP to report if the patient indicates signs of pain. Because the patient cannot communicate verbally, what signs of pain should the NAP report? a. Coughing, or audible gurgling. b. Foul-smelling breath or remaining secretions in the mouth. c. Increased restlessness or a sudden change in vital signs. d. Ability of the patient to move the tube with the tongue or to bite down on the tube.
c. Increased restlessness or a sudden change in vital signs.
A patient with a weak cough has secretions in the lower airway. What would be an appropriate response by the nurse? a. Oropharyngeal suctioning. b. Nasopharyngeal suctioning. c. Nasotracheal suctioning. d. Quad cough.
c. Nasotracheal suctioning.
An 18-year-old male presents with shortness of breath and chest pain, which he says has gotten progressively worse since yesterday. He is diagnosed with a spontaneous pneumothorax. He will be placed on a disposable, three-chambered ,closed chest drainage system with suction. His preprocedure vital signs are: temperature is 99° F, pulse 77, respiration 30 with diminished breath sounds on the right, blood pressure 120/80, and SaO2 90%. Which vital signs support the diagnosis of spontaneous pneumothorax? (Select all that apply.) a. Temperature b. Pulse c. Respiration d. Blood pressure e. Oxygen saturation
c. Respiration e. Oxygen saturation
Which of the following tasks associated with a chest tube is the responsibility of the nurse? a. Obtaining informed consent prior to the procedure b. Removing the chest tube when the order is received c. Setting up the equipment, positioning the patient positioning, and monitoring patient status d. Inserting the chest tube, connecting it to a drainage system, and monitoring output
c. Setting up the equipment, positioning the patient positioning, and monitoring patient status
After the NAP performs routine vital signs on the patient, the NAP reports to the nurse that the patient is restless, and it sounds like the patient is gurgling. Vital sign readings indicate a pulse of 72, respiratory rate of 20 breaths per minute, and a pulse oximetry of 89%. What is the most appropriate action at this time? a. Document the normal findings. b. Consult with the physician regarding need for a bronchodilator. c. Suction the patient's airway. d. Have the patient take a deep breath and reassess pulse oximetry.
c. Suction the patient's airway
A patient with a hemothorax has a posterior chest tube located laterally in the fifth intercostal space connected to a water-seal drainage system. Pre-procedure vital signs were: temperature 99.0° F, pulse 104, respiration 26, and shallow blood pressure 144 over 92, and oxygen saturation 90%. You are evaluating the patient's outcome. The physician should be notified of which of the following findings? (Select all that apply.) a. Temperature 99.0° F, pulse 80, respiration 20, blood pressure 130 over 80, pulse oximetry 93% b. Drainage changing to serous color c. Temperature 98.0° F, pulse 124, respiration 28, blood pressure 100 over 50, pulse oximetry 85% d. Bubbling in water-seal chamber immediately after chest tube insertion e. Bright-red drainage 8 hours after insertion f. 500 mL of drainage in 24 hours g. Asymmetrical chest movement
c. Temperature 98.0° F, pulse 124, respiration 28, blood pressure 100 over 50, pulse oximetry 85% e. Bright-red drainage 8 hours after insertion g. Asymmetrical chest movement
A ________ occurs when air enters the pleural cavity through a perforation in the pleura covering the lung, such as with the rupture of an emphysematous bleb or superficial lung abscess.
closed pneumothorax
A student nurse is working as a tutor for a group of freshman physiology students. Which statement, if made by someone in the study group, would require correction? a. "Normally, atmospheric pressure in the pleural space is negative ( -4 to -10 mm Hg)." b. "Besides difficulty breathing, an indication of a tension pneumothorax is a shift of the contents in the mediastinum (e.g., trachea and heart) to the opposite ( unaffected) side of the chest." c. "Kinking or clamping of the chest tube can result in a tension pneumothorax." d. "Physiologically, inspiration requires less work than expiration."
d. "Physiologically, inspiration requires less work than expiration."
Which of the following is an inaccurate step in the implementation of closed inline suctioning? Hand hygiene and clean gloves have already been applied. a. Attach suction. Hyperoxygenate the patient. Unlock the suction control mechanism. Pick up the suction catheter in the enclosed plastic sleeve with your dominant hand. b. Wait until the patient inhales or the ventilator delivers a breath and then quickly but gently insert the catheter on the next inhalation. c. Apply suction by squeezing on the suction control mechanism while withdrawing the catheter. Be sure to withdraw the catheter completely into the plastic sheath. d. Close the saline port and attach the saline syringe or vial. Squeeze the vial or push the syringe. Turn off the suction. Document.
d. Close the saline port and attach the saline syringe or vial. Squeeze the vial or push the syringe. Turn off the suction. Document.
Which of the following, if exhibited by the patient, would indicate late hypoxia? a. Restlessness b. Anxiety c. Eupnea d. Cyanosis
d. Cyanosis
An RN and an NAP are caring for a group of patients. Which of the following would be an appropriate action? a. Delegate assisting the physician in chest tube insertion to the NAP so the RN can take report on a new admission. b. Delegate milking or stripping the chest tube to the NAP while the RN administers pain medication to the patient. c. Delegate to the NAP clamping the chest tube while ambulating the patient in the hall three times a day. d. Delegate to the NAP informing the nurse if there is a disconnection of the system, sudden bleeding, or a sudden cessation of bubbling.
d. Delegate to the NAP informing the nurse if there is a disconnection of the system, sudden bleeding, or a sudden cessation of bubbling.
Which step in the sequence of nasopharyngeal suctioning requires correction? a. Perform hand hygiene. Connect suctioning tubing to the suction machine and turn it on. Have supplemental oxygen available. b. Maintaining sterile technique, open suction catheter. Fill the basin with 100 mL of sterile saline/water. Open the package of water-soluble lubricant. c. Apply sterile gloves. Attach suction catheter to connecting tubing. Test the assembled suctioning equipment. d. Lubricate the end of the catheter. Insert the catheter during expiration. Apply continuous suction for approximately 1 minute as the catheter is withdrawn.
d. Lubricate the end of the catheter. Insert the catheter during expiration. Apply continuous suction for approximately 1 minute as the catheter is withdrawn
A patient has a pleural effusion caused by a malignancy in her left lung. Following a needle aspiration, she experienced a 40% collapse of her left lower lung. She had a chest tube inserted to remove the excess fluid and air that collected in her pleural space. She has a waterless drainage system with a diagnostic indicator, which is attached to suction. How will the nurse best determine whether the patient is developing an air leak? a. By periodically lifting and draining the tube to the collection device. b. By clamping the tube and assessing the patient for signs of respiratory distress. c. The nurse notices the suction float ball fails to remain at the prescribed setting. d. The nurse observes bubbling in the diagnostic indicator chamber.
d. The nurse observes bubbling in the diagnostic indicator chamber
The nurse is assisting the physician to insert a chest tube. Before the procedure, the nurse prepares the drainage system to ensure that it will operate correctly. The nurse opens the drainage system and adds sterile water to the suction control chamber according to the manufacturer's directions. The nurse then connects the tubing to the suction control chamber and to the suction source. The nurse clamps the tube that will go to the patient and turns the suction on to check the system for any air leaks. Since no air leaks are found, the nurse unclamps the tube and leaves the suction on so that it is ready to be connected to the patient. Which step made by the nurse requires correction? a. The nurse performed all steps correctly. b. The nurse should not connect the tubing from the suction control chamber to the suction source. c. The nurse should not clamp the tube that will go to the patient. d. The nurse should turn the suction off before it is connected to the patient.
d. The nurse should turn the suction off before it is connected to the patient.
The nurse is assisting the physician to insert a chest tube. Which of the following activities, if performed by the nurse, requires correction? a. The nurse holds the anesthetic vial so the physician can visualize the label and verify the contents and dosage. b. The nurse cleans the top of the vial with an alcohol wipe and then turns it upside down so that the physician can withdraw the amount of drug needed. c. The nurse obtains the pulse, respiration, and blood pressure during the procedure. Using sterile technique, the nurse holds the drainage tube while the physician connects the chest tube. d. The nurse tapes the connection between the chest tube and the drainage tube with a figure-eight pattern and makes sure the tubing is coiled on the floor. e. The nurse marks the drainage chamber with the start date and time, the beginning amount of drainage, and initials.
d. The nurse tapes the connection between the chest tube and the drainage tube with a figure-eight pattern and makes sure the tubing is coiled on the floor.
The staff nurse instructs the student nurse to keep the obturator of the tracheostomy tube at the patient's bedside. How does the student nurse know which is the obturator? a. The obturator is the part which can be removed and discarded or cleaned and replaced. b. The obturator is the part which must remain inserted to ensure patency of the tube. c. The obturator remains visible at the site of the insertion and aids in securing the entire system to the patient's neck. d. The obturator is more slender and longer than the inner or outer cannula, and is rounded at the tip.
d. The obturator is more slender and longer than the inner or outer cannula, and is rounded at the tip.
A patient suddenly becomes short of breath, is complaining of chest pain, and has a fall in blood pressure. The nurse auscultates the lung sounds and hears normal lung sounds on the left as well as very diminished lung sounds on the right. The patient's trachea appears to be deviated to the left. What should the nurse suspect? a. The patient has an open pneumothorax b. The patient has a hemothorax c. The patient has a pneumohemothorax d. The patient has a tension pneumothorax
d. The patient has a tension pneumothorax
The nurse is performing closed inline suctioning. Pre-procedure assessment indicated crackles and wheezes bilaterally, pulse rate 72, respiratory rate 20 breaths per minute, and pulse oximetry 89%. Which of the following indicates the nurse should stop suctioning and administer oxygen? a. The patient's respiratory rate remains unchanged. b. The patient's pulse oximetry increases to 94%. c. Thick clear sputum is obtained during suctioning. d. The patient's pulse increases to 114 beats per minute
d. The patient's pulse increases to 114 beats per minute.
During the patient's exhalation, the physician removes the chest tube. The physician then covers the site with occlusive petrolatum gauze. What is the purpose of this dressing? a. To prevent bacteria from entering the chest tube site b. To stop bleeding more rapidly at the chest tube site c. To provide more soothing comfort of excoriation at the chest tube site d. To prevent the entrance of air into the pleural cavity
d. To prevent the entrance of air into the pleural cavity
The nurse desires to suction the patient's left main stem bronchus. In what position should the patient be placed? a. Keep the patient's head in a neutral position and rotate the catheter counter-clockwise upon insertion. b. Keep the patient's head in a neutral position and rotate the catheter clockwise upon insertion. c. Turn the patient's head to the left. d. Turn the patient's head to the right.
d. Turn the patient's head to the right.
The nurse is performing endotracheal tube care. Which step is an appropriate nursing action for performing this skill? a. Fold the tape that holds the endotracheal tube in place lengthwise to prevent it from sticking to the patient's head/hair. b. Use the tongue blades to inspect the patient's oral cavity for sores. c. Rotate the endotracheal tube to the opposite side of the mouth only if a lesion has developed under the tube. d. Use two people to carry out the procedure.
d. Use two people to carry out the procedure.
Which of the following would indicate the patient with a chest tube connected to suction is ready to have the chest tube removed? . After 2 hours, tidaling has ceased. a. There is 500 mL of drainage in 24 hours. b. The drainage has changed from red to serous. c. These is a presence of a mediastinal shift. d. After 3 days, tidaling has ceased for 24 hours. e. Hyperresonance occurs upon percussion.
e. Hyperresonance occurs upon percussion
What clinical signs and symptoms do you expect after a chest tube insertion? a. Shallow, rapid respirations b. Asymmetrical chest movement c. Diaphoretic d. Cyanotic e. Increased chest pain f. Normal rate and depth of breathing
f. Normal rate and depth of breathing
A__________ is an accumulation of blood and fluid in the pleural cavity between the parietal and visceral pleura, usually as a result of trauma. If left untreated, the accumulation of blood in the pleural space collapses lung tissue and ultimately affects cardiac output.
hemothorax
An ___________ occurs when the air enters through a perforation of the chest wall, such as the result of chest trauma, an automobile accident, a gunshot wound, or a stab wound.
open pneumothorax
A ___________ is a collection of air in the pleural space causing a collapse of lung tissue.
pneumothorax
