Respiratory System (Med Surg)

The staff educator is teaching new staff about chest drainage systems. What would be the criteria for use of a chest drainage system? 1. Post thoracotomy 2. Spontaneous pneumothorax 3. Bronchial Asthma 4. Chest trauma resulting in pneumothorax 5. Pleurisy 1 2 3 3 4 5 1 3 5 1 2 4 2 3 4 1 3 5 All of the above

1 2 4

In the absence of fluctuation in the water-seal chamber, which of the following should be suspected: 1. Kinks along tubing 2. Blood clot in the tube 3. Air leak in the tube \ 4. Lung re-expansion 123 234 134 124

134

Which of the following should be readily available in the bedside of a client with chest tube in place? A tracheostomy tray Another sterile chest tube A bottle of sterile water A clamp

A bottle of sterile water

What would the critical care nurse recognize as a condition that may indicate the patient's need to have a tracheostomy? A patient with a respiratory rate of 10 breaths per minute A patient who requires permanent ventilation A patient who exhibits symptoms of dyspnea A patient with respiratory acidosis

A patient who requires permanent ventilation

The nurse is preparing to suction a patient with an endotracheal tube. What would be the nurse's first step in the suctioning process? Explain the procedure to the patient before beginning and offer reassurance during suctioning. Turn on suction source (pressure should not exceed 120 mm Hg). Assess the patient's lung sounds and SaO2 via pulse oximeter. Perform hand hygiene. Put on nonsterile gloves, goggles, gown, and mask.

Assess the patient's lung sounds and SaO2 via pulse oximeter.

Which of the following assessments would be most appropriate for determining the correct placement of an ET to a mechanically ventilated client: Assessing a client's skin color Monitoring the respiratory rate Verifying the amount of cuff inflation Auscultating lung sounds bilaterally

Auscultating lung sounds bilaterally

Which finding is the best indication that a client with ineffective airway clearance needs suctioning? Oxygen saturation Respiratory rate Breath sounds Arterial blood gases

Breath sounds

A client who underwent a lobectomy, and has a water-seal chest drainage system is breathing with a little more effort and at a faster rate than 1 hour ago. The client's pulse rate is also increased. Which of the following action should the nurse implement? Check the tubing to ensure that the client is not lying on it or kinking it Increase suction Lower the drainage bottle to 2-3 feet below the level of client's chest Ensure the chest tube has 2 clamps on it to prevent air leaks

Check the tubing to ensure that the client is not lying on it or kinking it

A group of nursing students is practicing suctioning technique in the lab. One student asks what the benefit of closed- suctioning is. What would be the instructor's best response?( Closed-suctioning increases hypoxemia. Closed- suctioning decreases hypercapnia. Closed- suctioning decreases hypoxemia. Closed- suctioning increases hypercapnia.

Closed- suctioning decreases hypoxemia.

A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action? . Clamp the Chest tube Call the surgeon immediately Continue to monitor the rate of drainage Prefer for blood transfusion

Continue to monitor the rate of drainage

On the way to an x-ray examination, a client with a chest tube becomes confused and pulls the chest tube out. The nurse immediate action should be to: Place the client in supine position Hold the insertion site open with a kelly clamp Cover the dressing with the cleanest material available Instruct the client to breathe deeply until help arrives.

Cover the dressing with the cleanest material available

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 avoid pressure on the tracheal wall? Cuff pressures should be maintained between 10 and 15 mm Hg Cuff pressures should be maintained between 15 and 20 mm Hg Cuff pressures should be maintained between 20 and 25 mm Hg Cuff pressures should be maintained between 25 and 30 mm Hg

Cuff pressures should be maintained between 15 and 20 mm Hg

In doing chest vibration, the vibrating motion is produced by the: Wrist Fingers Shoulders Arms

Fingers

When performing postural drainage, which of the following factor promotes the movement of secretions from the lower to the upper respiratory tract? Friction between the cilia Force gravity Sweeping motion of the cilia involuntary muscles contraction

Force gravity

The doctor is preparing to remove chest tubes from the client's left chest. In preparation for the removal, the nurse should instruct the client to: Breathe normally Hold his breath and bear down Take a deep breath Sneeze on command

Hold his breath and bear down

You are the nurse caring for a patient who is scheduled to have a thoracotomy. You are planning to provide preoperative teaching and know to share what information with the patient? How to milk the chest tubing How to splint the incision when coughing How to care for the wound How to recognize signs of respiratory distress

How to splint the incision when coughing

A client with pulmonary embolus is intubated and placed on mechanical ventilation. When suctioning the endotracheal tube, Nurse MAY should Apply suction while inserting the catheter to immediately clear the airway. Hyperoxygenate the client with 100% oxygen before and after suctioning. Use short, jabbing movements of the catheter to loosen secretions. Suction two or three times in quick successions to remove secretions.

Hyperoxygenate the client with 100% oxygen before and after suctioning.

In a three-way bottle chest drainage with suction, the part that stabilize the normal negative pressure in the lungs is to: Question Immerse tube tip of the tube in 2 - 3 cm. of sterile NSS Immerse the tube of the suction control bottle in 10 to 20 cm. of sterile NSS Control the suction pressure where the suction bottle is connected Ensure opening of the airway vent.

Immerse the tube of the suction control bottle in 10 to 20 cm. of sterile NSS

What kind of bubbling is normally expected in the Suction bottle of chest tube drainage: Intermittent Fluctuating Tidaling Continuous

Intermittent

A nurse is explaining a chest tube to family members who do not understand where it is placed. What would the nurse tell them? It is inserted into the space between the lining of the lungs and the ribs. I don't exactly know, but I will make sure the doctor comes to explain. It is inserted directly into the lung itself, connecting to a lung airway. It is inserted into the peritoneal space and drains into the lungs.

It is inserted into the space between the lining of the lungs and the ribs.

What would be the priority goal established for a client with asthma who is being discharged from the hospital? The client: Is able to obtain pulse oximeter readings Demonstrate use of metered dose inhaler Knows the primary care provider's office hours Can identify the foods that may cause wheezing

Knows the primary care provider's office hours

While assessing thoracotomy incisional area from which a chest tube exists, the nurse feels a crackling sensation under the fingertips along the entire incision . Which of the following should be the nurse first action: Lower the head of the bed and call the physician Prepare an aspiration tray Mark the area with a skin pencil at the outer periphery of the crackling Turn off the suction of the chest drainage system

Mark the area with a skin pencil at the outer periphery of the crackling

The nursing instructor is teaching her clinical group about the care of an adult patient requiring mechanical ventilation. What would the instructor teach the students? Keep the patient in a low Fowler's position. Perform tracheostomy care at least every 12 hours. Keep the patient on bed rest continually Monitor cuff pressure every 8 hours.

Monitor cuff pressure every 8 hours.

In case of accidental dislodge of the tracheostomy tube, what is very necessary at bedside to help in emergency re-insertion: Red-plug button A spare of inner cannula Obturator A Clamp

Obturator

The nursing instructor is explaining how to provide postural drainage to a client. What would be an appropriate nursing action for providing postural drainage that the instructor would teach her students? Administering physiotherapy in an upright position Performing the procedure following the patient's meals Applying percussion firmly to bare skin Positioning the patient using pillows to promote postural drainage

Positioning the patient using pillows to promote postural drainage

The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the nurse? Breath sounds can be heard bilaterally Mist is visible in the T-piece Pulse Oximetry of 88% Client unable to speak

Pulse Oximetry of 88%

You need to assess arterial oxygen saturation (SaO2) in your patient. What is the best procedure accomplish this? Incentive spirometry Arterial blood gas (ABG) measurement Peak flow measurement Pulse oximetry

Pulse oximetry

In a two-bottle system for a chest-tube drainage, the water-seal system is seen in the: First Bottle Second Bottle Both bottles

Second Bottle

Which of the following nursing interventions would promote effective airway clearance in a client with acute respiratory distress? Administer oxygen every 2 hours Turning the client every 4 hours Administering sedatives to promote rest Suctioning if cough is ineffective

Suctioning if cough is ineffective

What can a nurse ask a patient to do before suctioning to prevent hypoxemia? Sit in an upright position and cough Breathe normally for at least 5 minutes Lie flat in bed and practice relaxation Take several deep breaths

Take several deep breaths

The nurse is observing an elderly client use his MDI to administer his bronchodilator medication. Which of the following client's action should the nurse correct to improve client's technique: The client shake the inhaler immediately before use The client wait 30 seconds between puffs The client activates the MDI on inspiration The client holds his breath for 10 seconds after inhalation

The client wait 30 seconds between puffs

The nurse, caring for a patient with an endotracheal tube, recognizes that there are several disadvantages of an endotracheal tube. What would the nurse recognize as a disadvantage of endotracheal tubes? Mobility is limited. The patient is unable to speak. The patient requires oxygen support. The cough reflex is depressed.

The cough reflex is depressed.

A client has a chest tube attached to a water seal drainage system and the nurse notes that the fluid in the chest tube and in the water-seal column has stopped fluctuating. which of the following is the explanation: The lung has fully expanded The lung has collapsed the chest tube is in the pleural space The mediatinal space has decreased

The lung has fully expanded

While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of a closed chest-drainage system. What should the nurse conclude? The system is functioning normally. The patient has a pneumothorax. The system has an air leak. The chest tube is obstructed.

The system has an air leak.

Frequent milking and clamping of chest-tubes are avoided to: To prevent hypoxemia of patient To prevent accidental dislodging of the tubes To prevent development of Tension Pneumothorax To prevent further clogging the tubes

To prevent development of Tension Pneumothorax

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 undergoing mechanical ventilation. The critical care nurse explains that to help prevent tracheal dilation, a complication of tracheostomy tube placement, the nurse should Suction the tracheostomy tube frequently. Use a cuffed tracheostomy tube. Use the minimal air leak technique with cuff pressure less than 25 cm H2O. Keep the tracheostomy tube plugged.

Use the minimal air leak technique with cuff pressure less than 25 cm H2O.