Saunders Pneumothorax, Cardiac tamponade, chest trauma
The nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube? Deflate the cuff on the tube. Place the inner cannula into the tube. Ensure that the client is able to speak. Ensure that the client is able to swallow
. Deflate the cuff on the tube. Plugging a tracheostomy tube is usually done by inserting the tracheostomy plug (decannulation stopper) into the opening of the outer cannula. This closes off the tracheostomy, and airflow and respiration occur normally through the nose and mouth. When plugging a cuffed tracheostomy tube, the cuff must be deflated. If it remains inflated, ventilation cannot occur, and respiratory arrest could result. A tracheostomy plug could not be placed in a tracheostomy if an inner cannula was in place. The ability to swallow or speak is unrelated to weaning and plugging the tube.
The nurse is assessing a client's tracheostomy and notes that the skin around the stoma appears swollen with no redness or drainage present. Which action would the nurse take next? Rationale, Strategy, Tip Palpate the skin around the stoma. Notify the primary health care provider (PHCP). Document the finding with no further intervention. Instruct the client to perform deep breathing exercises.
Palpate the skin around the stoma
he nurse is caring for a client who underwent a pleurodesis procedure to treat a recurrent pleural effusion. The medication was instilled into the chest tube at 1600 and subsequently clamped. At what time will the nurse unclamp the chest tube? 1800 2000 2200 2400
2400
A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? Cyanosis Hypotension Paradoxical chest movement Dyspnea, especially on exhalation
Paradoxical chest movement
The nurse is reviewing the pathophysiology of pleural effusion. The nurse knows that pleural fluid balance is managed by several mechanisms and correctly identifies which of the following as a cause for the development of pleural effusion? Select all that apply. Rationale, Strategy, Tip Answer Options Your Answers: Decreased oncotic pressure Lymphatic fluid outflow obstruction Increased pulmonary capillary pressure Decreased pulmonary capillary pressure Increased pleural membrane permeabili
Decreased oncotic pressure Lymphatic fluid outflow obstruction Increased pulmonary capillary pressure Increased pleural membrane permeability
A client is on continuous mechanical ventilation (CMV), and the low-pressure alarm sounds. The nurse would take which action? Make sure that the client is not lying on the ventilator tubing. Determine whether there are any disconnections in the ventilator tubing. Check to see if the client is biting on the endotracheal tube (ETT). Auscultate the lungs to determine whether the client needs to be suctioned.
Determine whether there are any disconnections in the ventilator tubing.
The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client? A low respiratory rate Diminished breath sounds The presence of a barrel chest A sucking sound at the site of injury
Diminished breath sounds
The low-exhaled volume alarm sounds on a mechanical ventilator of a client with an endotracheal tube. The nurse determines that the cause for alarm activation may be which complication? Excessive secretions Kinks in the ventilator tubing The presence of a mucous plug Disconnection of the ventilator tube
Disconnection of the ventilator tube
The nurse is caring for a client on a mechanical ventilator. The low-pressure alarm sounds. The nurse suspects that the most likely cause of the alarm is which finding? A tubing obstruction or kink The accumulation of secretions Disconnection of the ventilator tubing Condensation of water in the ventilator tubing
Disconnection of the ventilator tubing
The nurse caring for a client with pneumothorax who has a closed chest drainage system notes that the fluctuation (tidaling) in the water seal chamber has stopped. On the basis of this assessment finding, the nurse would suspect which occurrence? The system needs changing. Suction needs to be increased. Suction needs to be decreased. The chest tube may be obstructed.
The chest tube may be obstructed.
The nurse is assisting the primary health care provider (PHCP) with insertion of a chest tube in a client who sustained a chest injury. The nurse notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this observation, the nurse would take which action? Ensure that suction is turned on. Reinforce the occlusive dressing. Encourage the client to breathe deeply. Document the accurate functioning of the tube.
Document the accurate functioning of the tube.
The nurse is caring for a client with a pneumothorax who has a chest tube drainage system. The nurse notes a fluctuating water level on inspiration and expiration in the submerged tube in the water seal chamber of the chest tube drainage system. Which nursing action is appropriate? Suction the client. Increase the suction. Document the findings. Encourage coughing and deep breathing.
Document the findings
The nurse is assisting a pulmonologist with a pleurodesis to treat a client with recurrent pleural effusions. After the pulmonologist instills the medication into the pleural space, for how long would the nurse anticipate the chest tube drainage system will need to be clamped? Rationale, Strategy, Tip 2 hours 4 hours 6 hours 8 hours
8 hours
A client has been treated for pleural effusion with a thoracentesis. The nurse determines that this procedure has been effective if the nurse notes which assessment finding? Absence of dyspnea Increased severity of cough Dull percussion notes over lung tissue Decreased tactile fremitus over lung tissue
Absence of dyspnea
A client is on continuous mechanical ventilation (CMV) and the high-pressure alarm sounds. Which action would the nurse take to eliminate the problem? Silence the alarm to avoid disturbing the client. Check the ventilator circuit for any disconnections. Inflate the cuff of the endotracheal tube to a pressure of 25 mm Hg. Empty excess accumulated water from the ventilatory circuit tubing.
Empty excess accumulated water from the ventilatory circuit tubing.
The nurse is caring for a client who underwent a thoracentesis to treat pleural effusion. The pleural fluid testing results indicate the pleural fluid is cloudy and confirm the presence of white blood cells (WBCs). Which condition would the nurse suspect? Rationale, Strategy, Tip Cirrhosis Malignancy Chronic kidney disease Congestive heart failur
Malignancy
A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? Cyanosis Hypotension Paradoxical chest movement Dyspnea, especially on exhalation
Paradoxical chest movement Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest.
A primary health care provider (PHCP) tells the nurse that a client's chest tube is to be removed since pneumothorax is resolved. The nurse would bring which dressing materials to the bedside for the PHCP's use? Telfa dressing and Neosporin ointment Petrolatum gauze and sterile 4 × 4 gauze Benzoin spray and a hydrocolloid dressing Sterile 4 × 4 gauze, Neosporin ointment, and tape
Petrolatum gauze and sterile 4 × 4 gauze
A registered nurse who is orienting a new nursing graduate to the hospital emergency department instructs the new graduate to monitor a client for one-sided chest movement on the right side while the client is being intubated by the primary health care provider (PHCP). Which statement made by the new nursing graduate indicates understanding of the importance of this observation? "It will enter the left main bronchus if inserted too far." "It will enter the right main bronchus if inserted too far." "It may enter the left main bronchus if not inserted far enough." "It may enter the right main bronchus if not inserted far enough."
"It will enter the right main bronchus if inserted too far."
A client is diagnosed with a rib fracture and asks the nurse why strapping of the ribs is not being done. Which response by the nurse is most appropriate? "Strapping is useful only if the ribs are fractured in several places at once." "That's a good idea. I'll ask the doctor for a prescription for the needed supplies." "That isn't done because people often would develop pneumonia from the constricting effect on the lungs." "That might help you to breathe better, but this facility does not carry the necessary supplies in the stockroom. When you get home, you can purchase them at the medical supply store."
"That isn't done because people often would develop pneumonia from the constricting effect on the lungs."
The nurse has completed care for a client whose tracheostomy tube has a nondisposable inner cannula. Which action would the nurse perform prior to reinserting the inner cannula? Suction the client's airway. Wipe the inner cannula off with a clean washcloth. Dry the inner cannula thoroughly with sterile gauze. Allow the inner cannula to dry after washing it with sterile water.
Allow the inner cannula to dry after washing it with sterile water.
The nurse is caring for a client with a pneumothorax who has a chest tube drainage system. During repositioning of the client, the chest tube accidentally pulls out of the pleural cavity. Which is the initial nursing action? Apply an occlusive dressing. Reinsert the chest tube quickly. Contact the respiratory therapist. Contact the primary health care provider (PHCP).
Apply an occlusive dressing.
The nurse witnesses an accident whereby a pedestrian is hit by an automobile. The nurse stops at the scene and assesses the victim. The nurse notes that the victim is responsive and has suffered trauma to the thorax resulting in a flail chest involving at least three ribs. What is the nurse's priority action for this victim? : Assist the victim to sit up. Remove the victim's shirt. Turn the victim onto the side opposite the flail chest. Apply firm but gentle pressure with the hands to the flail segment.
Apply firm but gentle pressure with the hands to the flail segment.
The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs? Suctioning is required frequently. The client's skin and mucous membranes are light pink. Aspiration of gastric contents occurs during suctioning. Excessive secretions are suctioned from the tube and stoma.
Aspiration of gastric contents occurs during suctioning
The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate? Do nothing because this is an expected finding. Check for an air leak because the bubbling needs to be intermittent. Increase the suction pressure so that the bubbling becomes vigorous. Clamp the chest tube and notify the primary health care provider immediately.
Check for an air leak because the bubbling needs to be intermittent. Fluctuation with inspiration and expiration, not continuous bubbling, would be noted in the water seal chamber. Intermittent bubbling may be noted if the client has a known pneumothorax, but this would decrease as time goes on and as the pneumothorax begins to resolve. Therefore, the nurse would check for an air leak. If a wet chest drainage system is used, bubbling would be continuous in the suction control chamber and not intermittent. In a dry system, there is no bubbling. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system; in addition, increasing the suction can be harmful and is not done without a specific prescription to do so if using a wet system. Dry systems will allow for only a certain amount of suction to be applied; an orange bellow will appear in the suction window, indicating that the proper amount of suction has been applied. Chest tubes would be clamped only with a primary health care provider's prescription.
The nurse is reviewing the pleural fluid cytology report for a client with pleural effusion. The report describes the fluid as clear and pale yellow with no red blood cells (RBCs) or white blood cells (WBCs) detected. Based on these results, which underlying condition would the nurse suspect? Rationale, Strategy, Tip Answer Options Your Answers: Malignancy Pneumonia Tuberculosis Congestive heart failure
Congestive heart failure
The nurse determines that the client with pneumothorax who has a chest tube to a closed drainage system is experiencing an air leak. Which finding is indicative of this? Tidaling is absent. Gentle bubbling is observed in the suction control chamber. Vacillation of water in the water seal chamber occurs during respiration. Continuous bubbling is observed in the water seal chamber during inspiration and expiration.
Continuous bubbling is observed in the water seal chamber during inspiration and expiration.
The nurse determines that a client with a tracheostomy tube needs suctioning if which finding is noted? Rhonchi are auscultated. Pleural friction rub is heard. Fine crackles are auscultated. Pulse oximetry reading is 96%.
Rhonchi are auscultated.
Which clinical manifestations of a tension pneumothorax would be of immediate concern to the nurse? Select all that apply. Bradypnea Flattened neck veins Decreased cardiac output Hyperresonance to percussion Tracheal deviation to the opposite side
Decreased cardiac output Hyperresonance to percussion Tracheal deviation to the opposite side
The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action? Check for an air leak. Document the findings. Notify the primary health care provider. Change the chest tube drainage system.
Document the findings. Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent (not constant) bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Continuous bubbling during inspiration and expiration indicates that an air leak exists. If this occurs, it must be corrected. Notifying the primary health care provider and changing the chest tube drainage system are not indicated at this time.
To prevent postoperative atelectasis in a client recovering from an open cholecystectomy, what would the nurse do first? Request a cardiopulmonary consult. Teach the client to splint the incision. Teach the proper technique for huff coughing. Ensure that the client is experiencing adequate pain control.
Ensure that the client is experiencing adequate pain control.
A nursing student is developing a plan of care for a client with a chest injury who has a chest tube that is attached to a chest drainage system. Which intervention in the care plan indicates the need for further teaching for the student? Position the client in semi-Fowler's position. Add water to the suction chamber as it evaporates. Instruct the client to avoid coughing and deep breathing. Tape the connection sites between the chest tube and the drainage system.
Instruct the client to avoid coughing and deep breathing.
The nurse assesses for one-sided chest movement on the right while a client is being intubated by the primary health care provider. Which could occur with the endotracheal tube? It could enter the left main bronchus if inserted too far. It could enter the right main bronchus if inserted too far. It could enter the left main bronchus if not inserted far enough. It could enter the right main bronchus if not inserted far enough.
It could enter the right main bronchus if inserted too far.
The nurse is reading the report for a chest x-ray study in a client who has just been intubated. The report states that the tip of the endotracheal tube lies 1 cm above the carina. How does the nurse correctly interpret these findings? It is at the first tracheal cartilaginous ring. It is at the bifurcation of the right and left main bronchi. It is at the point at which the larynx connects to the trachea. It is at the area connecting the oropharynx to the laryngopharynx.
It is at the bifurcation of the right and left main bronchi.
The nurse is reviewing the ventilator settings on a client with an endotracheal tube attached to mechanical ventilation. The nurse notes that the tidal volume is set at 500 mL. How does the nurse interpret this setting? It is the amount of air delivered with each set breath. It is a breath that has a greater volume than the preset tidal volume. It is the number of breaths that the client will receive per minute by the ventilator. It is the fraction of inspired oxygen (FiO2) that is delivered to the client through the ventilator.
It is the amount of air delivered with each set breath.
The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment finding indicates the presence of this complication? Flat neck veins A pulse rate of 60 beats/minute Muffled or distant heart sounds Wheezing on auscultation of the lungs
Muffled or distant heart sounds Assessment findings associated with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention with clear lung sounds, and a falling blood pressure accompanied by pulsus paradoxus (a drop in inspiratory blood pressure greater than 10 mm Hg). The other options are not signs of cardiac tamponade.
The nurse is assisting a primary health care provider with the removal of a chest tube in a client with a resolved pneumothorax. The nurse would instruct the client to take which action? Stay very still. Exhale very quickly. Inhale and exhale quickly. Perform the Valsalva maneuver.
Perform the Valsalva maneuver. When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath and hold it, bear down, and exhale). After premedicating the client for pain 30 minutes prior to the procedure if desired, the tube is quickly withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed.
The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is appropriate? Continue to suction. Stop the procedure and reoxygenate the client. Ensure that the suction is limited to 15 seconds. Notify the primary health care provider immediately.
Stop the procedure and reoxygenate the client. During suctioning, the nurse would monitor the client closely for adverse effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If adverse effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.
The nurse is assisting in caring for a client after removal of an endotracheal tube. Which finding would be reported to the primary health care provider (PHCP) immediately? Stridor Lung congestion Occasional pink-tinged sputum Respiratory rate of 26 breaths/min
Stridor
The nurse is preparing for removal of an endotracheal (ET) tube from a client. In assisting the primary health care provider with this procedure, which is the initial nursing action? Deflate the cuff. Suction the ET tube. Turn off the ventilator. Obtain a code cart, and place it at the bedside.
Suction the ET tube.
The nurse is caring for a client with a tracheostomy tube attached to a ventilator. The high-pressure alarm sounds on the ventilator. The nurse would plan to perform which action? Suction the client. Evaluate the cuff for a leak. Assess for a disconnection. Notify the respiratory therapist.
Suction the client.
A client who sustained a chest injury has a chest tube attached to a water seal drainage system. As part of routine nursing care, the nurse would ensure that which intervention is implemented? The water seal chamber has continuous bubbling, and assessment for crepitus is done once a shift. The amount of drainage into the chest tube is noted and recorded every 24 hours in the client's record. The suction control chamber has sterile water added every shift, and the system is kept below waist level. The connection between the chest tube and the drainage system is taped, and an occlusive dressing is maintained at the insertion site.
The connection between the chest tube and the drainage system is taped, and an occlusive dressing is maintained at the insertion site.
The nurse is caring for a client with a chest injury who has a dry suction chest drainage system. During assessment of the drainage system, what would the nurse expect to find? Select all that apply. The dry suction control regulation set to the prescribed amount The water-filled suction control chamber filled to the prescribed amount Increased intermittent bubbling in the water seal chamber when the system is to gravity Continuous bubbling in the water seal chamber when the system is connected to suction The drainage in the collection chamber marked each shift to monitor the amount of drainage
The dry suction control regulation set to the prescribed amount The drainage in the collection chamber marked each shift to monitor the amount of drainage
The nurse is monitoring the function of a chest tube that is attached to a drainage system in a client with pneumothorax. The nurse notes that the fluid in the water seal chamber rises with inspiration and falls with expiration. The nurse determines that which is occurring? Tidaling is present. There is a leak in the system. The client has residual pneumothorax. Suction needs to be added to the system.
Tidaling is present
The nursing instructor is reviewing the various complications of a tracheostomy. The nursing instructor determines teaching has been effective if the nursing student correctly identifies which of the following conditions as tracheal dilation and cartilage erosion? Tracheomalacia Tracheal stenosis Tracheoesophageal fistula (TEF) Trachea-innominate artery fistula
Tracheomalacia
The nurse has assisted the primary health care provider and the anesthesiologist with placement of an endotracheal (ET) tube for a client in respiratory distress. What is the initial nursing action to evaluate proper ET tube placement? Tape the ET tube in place, and note the centimeter marking at the lip line. Ask the radiology department to obtain a stat portable radiograph at the client's bedside. Use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds. Attach the ET tube to the ventilator and determine whether the client is able to tolerate the tidal volume prescribed.
Use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds.
The low-pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse would take what initial action? Administer oxygen. Check the client's vital signs. Ventilate the client manually. Start cardiopulmonary resuscitation.
Ventilate the client manually.
The nurse is caring for a client who is mechanically ventilated, and the high-pressure ventilator alarm is sounding. The nurse understands that which complications may cause this alarm? Select all that apply. Water or a kink in the tubing Biting on the endotracheal tube Increased secretions in the airway Disconnection or leak in the system The client ceasing spontaneous breathing
Water or a kink in the tubing Biting on the endotracheal tube Increased secretions in the airway
the nurse is providing immediate postprocedure care to a client who had a thoracentesis to relieve a tension pneumothorax that resulted from rib fractures. The goal is that the client will exhibit normal respiratory functioning, and the nurse provides instructions to assist the client with this goal. Which client statement indicates that further instruction is needed? "I will lie on the affected side for an hour." "I can expect a chest x-ray exam to be done shortly." "I will let you know at once if I have trouble breathing." "I will notify you if I feel a crackling sensation in my chest." t."
"I will lie on the affected side for an hour."
The nurse is caring for a client who is mechanically ventilated and is monitoring for complications of mechanical ventilation. Which assessment finding, if noted by the nurse, indicates the need for follow-up? Answer Options Muscle weakness in the arms and legs A temperature of 98.6° F (37° C), decreased from 99.0° F (37.2° C) A blood pressure of 90/60 mm Hg, decreased from 112/78 mm Hg A heart rate of 80 beats/minute, decreased from 85 beats/minute
A blood pressure of 90/60 mm Hg, decreased from 112/78 mm Hg Complications of mechanical ventilation include the following: hypotension caused by application of positive pressure, which increases intrathoracic pressure and inhibits blood return to the heart; pneumothorax or subcutaneous emphysema as a result of positive pressure; gastrointestinal alterations such as stress ulcers; malnutrition if nutrition is not maintained; infections; muscular deconditioning; and ventilator dependence or inability to wean. Some muscle weakness is expected. Options 1, 2, and 4 present normal assessment findings.
The experienced nurse is teaching a new graduate nurse about tracheostomy care. The experienced nurse would determine teaching has been effective if the new graduate nurse states that which client has an immature tracheostomy? A client who underwent a tracheotomy 2 days ago A client who underwent a tracheotomy 8 days ago A client who underwent a tracheotomy 10 days ago A client who underwent a tracheotomy 1 month ag
A client who underwent a tracheotomy 2 days ago
The nurse is caring for a client with an endotracheal tube attached to a mechanical ventilator. The high-pressure alarm sounds, and the nurse assesses the client. The nurse determines that the cause of the alarm is most likely to be due to which complication? A kink in the ventilator circuit A leak in the endotracheal tube cuff Displacement of the endotracheal tube A disconnection of the ventilator tubing
A kink in the ventilator circuit
The nurse is assessing a client hospitalized with acute pericarditis. The nurse monitors the client for cardiac tamponade, knowing that which signs are associated with this complication of pericarditis? Select all that apply. Bradycardia Pulsus paradoxus Distant heart sounds Falling blood pressure (BP) Distended jugular veins
Pulsus paradoxus Distant heart sounds Falling blood pressure (BP) Distended jugular veins
The nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. The nurse immediately applies sterile gauze over the chest tube insertion site. Which is the nurse's next action? Replace the chest tube system. Obtain a pulse oximetry reading. Call the primary health care provider. Place the client in a Trendelenburg's position.
Call the primary health care provider. If the chest drainage system is dislodged from the insertion site, the nurse immediately applies sterile gauze over the site and calls the primary health care provider. The nurse would maintain the client in an upright position. A new chest tube system may be attached if the tube requires insertion, but this would not be the next action. Pulse oximetry readings would assist in determining the client's respiratory status, but the priority action would be to call the health care provider in this emergency situatio
The nurse has assisted the primary health care provider (PHCP) with the insertion of a chest tube in a client who sustained a chest injury and has a pneumothorax. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment finding, which action is most appropriate? Inform the PHCP. Continue to monitor the client. Reinforce the occlusive dressing. Encourage the client to deep breathe
Continue to monitor the client. The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, a dependent loop exists, the suction is not working properly, or the lung has reexpanded. Because this finding is expected, it is not necessary to notify the PHCP. The presence of fluctuation of the fluid level in the water seal chamber does not indicate that the dressing needs reinforcement. Although it is important for the client to cough and deep breathe, this action is unrelated to the situation presented in the question.
The nurse is assessing the functioning of a chest tube drainage system in a client with a chest injury who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. Excessive bubbling in the water seal chamber Vigorous bubbling in the suction control chamber Drainage system maintained below the client's chest 50 mL of drainage in the drainage collection chamber Occlusive dressing in place over the chest tube insertion site Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation
Drainage system maintained below the client's chest 50 mL of drainage in the drainage collection chamber Occlusive dressing in place over the chest tube insertion site Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation
The nurse is caring for a client with a tracheostomy receiving supplemental oxygen via a tracheostomy mask and is preparing to perform tracheostomy care. While preparing the supplies, the nurse notes the tracheostomy tube is pulsing, there is bleeding from the stoma, and the client is increasingly restless. The nurse calls for a rapid response team (RRT) and removes the tracheostomy tube. Which action would the nurse take next? Obtain blood type and crossmatch Ensure intravenous (IV) access patency Apply direct pressure to the source of bleeding Assist the primary health care provider (PHCP) with endotracheal intubation
Ensure intravenous (IV) access patency
While changing the tapes on a newly inserted tracheostomy tube, the client coughs and the tube is dislodged. Which is the initial nursing action? Grasp the retention sutures to spread the opening. Call the primary health care provider to reinsert the tube. Call the respiratory therapy department to reinsert the tracheotomy. Cover the tracheostomy site with a sterile dressing to prevent infection
Grasp the retention sutures to spread the opening
The nurse is preparing to perform suctioning for a client with a tracheostomy tube and gathers the supplies needed for the procedure. What is the initial nursing action? Hyperoxygenate the client. Set the suction pressure range at 150 mm Hg. Place the catheter into the tracheostomy tube. Apply suction on the catheter, and insert it into the tracheostomy tube.
Hyperoxygenate the client.
A chest x-ray report for a client indicates the presence of a left apical pneumothorax. The nurse would assess the status of breath sounds in that area by placing the stethoscope in which location? Just under the left clavicle Midsternum, 1 inch to the left Over the fifth intercostal space Midsternum, 1 inch to the right
Just under the left clavicle The apex of the lung is the rounded, uppermost part of the lung. Therefore, the nurse would place the stethoscope just under the left clavicle. All of the other options are incorrect locations for assessing the left apex.
The nurse is preparing for suctioning an unconscious client who has a tracheostomy. The nurse would perform which actions for this procedure? Select all that apply. Keeping a supply of suction catheters at the bedside Auscultating breath sounds to determine the need for suctioning Hyperoxygenating the client before, during, and after suctioning Intermittently suctioning during insertion of the suction catheter Placing suction on the catheter for at least 30 seconds to ensure that all secretions are removed
Keeping a supply of suction catheters at the bedside Auscultating breath sounds to determine the need for suctioning Hyperoxygenating the client before, during, and after suctioning
A client who has just suffered a severe flail chest is experiencing severe pain and dyspnea. The client's central venous pressure (CVP) is rising, and the arterial blood pressure is falling. Which condition would the nurse interpret that the client is experiencing? Fat embolism Mediastinal shift Mediastinal flutter Hypovolemic shock
Mediastinal flutter
A client who is intubated and receiving mechanical ventilation is at risk for infection. The nurse would include which measures in the care of this client? Select all that apply. Monitor the client's temperature. Use sterile technique when suctioning. Use the closed-system method of suctioning. Monitor sputum characteristics and amounts. Drain water from the ventilator tubing into the humidifier bottle.
Monitor the client's temperature. Use sterile technique when suctioning. Use the closed-system method of suctioning. Monitor sputum characteristics and amounts.
The nurse caring for a client who sustained a chest injury and who has a chest tube drainage system notes constant bubbling in the water seal chamber. Which nursing action is appropriate? Reposition the client. Change the chest tube drainage system. Notify the primary health care provider (PHCP). No action is necessary because this is a normal, expected finding
Notify the primary health care provider (PHCP).
A client begins to experience drainage of small amounts of bright red blood from the tracheostomy tube 24 hours after a supraglottic laryngectomy. Which is the best nursing action? Increase the frequency of suctioning. Add moisture to the oxygen delivery system. Document the character and amount of drainage. Notify the primary health care provider (PHCP).
Notify the primary health care provider (PHCP). Immediately after laryngectomy, a small amount of bleeding occurs from the tracheostomy that resolves within the first few hours. Otherwise, bleeding that is bright red may be a sign of impending rupture of a vessel. The bleeding in this instance represents a potential threat to life, and the PHCP is notified to further evaluate the client and suture or repair the source of the bleeding. The other options do not address the urgency of the problem. Failure to notify the PHCP places the client at risk.
The nurse is caring for a client with a pneumothorax and a chest tube who accidentally disconnects the tube from the drainage system when trying to get out of bed. The nurse immerses the end of the tube in sterile water. What immediate action would the nurse take? Obtain a new drainage system. Ask the client to hold their breath. Place the client in a prone position. Place a sterile dressing over the chest tube insertion site.
Obtain a new drainage system.
The nurse is planning care for a client who is scheduled for a tracheostomy procedure. What equipment would the nurse plan to have at the bedside when the client returns from surgery? Obturator Oral airway Epinephrine Tracheostomy set with the next larger size
Obturator
The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse would expect to note which finding? Slow, deep respirations Rapid, deep respirations Paradoxical respirations Pain, especially with inspiration
Pain, especially with inspiration Rib fractures result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest.
The nurse is monitoring the chest tube drainage system in a client with a pneumothorax. The nurse notes constant bubbling in the water seal chamber. Which is the most appropriate initial nursing action? Continue to monitor. Document the findings. Change the chest tube drainage system. Perform a focused respiratory assessment
Perform a focused respiratory assessment. Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent (not constant) bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Continuous bubbling during inspiration and expiration indicates that an air leak exists. If this occurs, it must be corrected. A focused respiratory assessment needs to be done immediately, specifically checking for respiratory difficulty and subcutaneous emphysema. Changing the chest tube drainage system is not indicated at this time. Continuing to monitor the bubbling delays necessary intervention. Although documenting is necessary, it is not the most appropriate initial action
The nurse is preparing to assist a client with a cuffed tracheostomy tube to eat. What intervention is the priority before the client is permitted to drink or eat? Place the client in high-Fowler's position. Deflate the cuff on the tracheostomy tube. Maintain the head of the bed in a low-Fowler's position. Place the tray in a comfortable position in front of the client.
Place the client in high-Fowler's position.
The nurse is assisting a radiologist to facilitate a thoracentesis for a client with pleural effusion. The nurse assists the client to a position that widens the spaces between the ribs to help drain which area? Alveoli Trachea Pleural space Main bronchi
Pleural space
A client with an endotracheal tube who is being mechanically ventilated is visibly anxious. What is the best nursing action? Ask a family member to stay with the client at all times. Encourage the client to sleep until arterial blood gas results improve. Ask the primary health care provider for a prescription for succinylcholine. Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed.
Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed.
78 of 89 78 The nurse is assisting a client with a tracheostomy turn in bed when the tube gets caught under the client, causing the tracheostomy tube to be pulled out. The nurse calls a rapid response team (RRT) and attempts to replace the tracheostomy tube with the same size tube as the tube that was pulled out and is unsuccessful. While waiting for the RRT, which action would the nurse take? Auscultate bilateral breath sounds. Place the client in the low Fowler's position. Ventilate the client using a manual resuscitation bag with the stoma unoccluded. Reattempt the insertion with a tracheostomy tube that is one size smaller than the original tracheostomy tube
Reattempt the insertion with a tracheostomy tube that is one size smaller than the original tracheostomy tube
A client experienced an open pneumothorax (sucking wound), which has been covered with an occlusive dressing. The client begins to experience severe dyspnea, and the blood pressure begins to fall. The nurse would first perform which action? Remove the dressing. Reinforce the dressing. Call the primary health care provider (PHCP). Measure oxygen saturation by oximetry.
Remove the dressing. Placement of a dressing over a chest wound could convert an open pneumothorax to a closed (tension) pneumothorax. This may result in a sudden decline in respiratory status, mediastinal shift with twisting of the great vessels, and circulatory compromise. If clinical changes occur, the nurse would remove the dressing immediately, allowing air to escape. Therefore, reinforcing the dressing is an incorrect action. The nurse would measure oxygen saturation by oximetry and would call the PHCP, but these would not be the first actions in this situation.
The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance? Respiratory acidosis from inadequate ventilation Respiratory alkalosis from anxiety and hyperventilation Metabolic acidosis from calcium loss due to broken bones Metabolic alkalosis from taking analgesics containing base products
Respiratory acidosis from inadequate ventilation
A client with a tracheostomy tube who is on a ventilator is at risk for reduced gas exchange. The nurse would assess for which finding as the best indicator of adequate ongoing respiratory status? Oxygen saturation of 89% Respiratory rate of 16 breaths/minute Moderate amounts of tracheobronchial secretions Small to moderate amounts of frank blood suctioned from the tube
Respiratory rate of 16 breaths/minute Impaired gas exchange could occur after tracheostomy because of excessive secretions, bleeding into the trachea, restricted lung expansion because of immobility, or concurrent respiratory conditions. An oxygen saturation of 89% is less than optimal. A respiratory rate of 16 breaths/minute is in the normal range.
A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition? Right pneumothorax Pulmonary embolism Displaced endotracheal tube Acute respiratory distress syndrome
Right pneumothorax
A client has had an invasive abdominal surgery to relieve an obstruction of the common bile duct. The client's surgery is completed, and the client has been transferred to the postanesthesia care unit (PACU). The PACU nurse observes that the client suddenly appears red in the face and appears to be coughing despite the presence of an endotracheal tube and ventilator support. What action would the PACU nurse take first? Suction the client through the endotracheal tube. Instruct the client in the use of an incentive spirometer. Turn the client from a 30-degree lateral position to a supine position. Instruct the client to use a communication board to tell the nurse what is wrong.
Suction the client through the endotracheal tube.
client with an endotracheal tube attached to mechanical ventilation begins to cough, and the client's face appears flushed. Which action would the nurse take first? Call respiratory therapy. Contact the physician. Check the client's blood pressure. Suction the client through the endotracheal tube.
Suction the client through the endotracheal tube.
The nursing instructor is observing a nursing student suctioning a client through a tracheostomy tube. Which observation by the nursing instructor indicates an action by the student requiring the need for further instruction? Suctioning the client every hour Applying suction only during withdrawal of the catheter Hyperventilating the client with 100% oxygen before suctioning Applying suction intermittently during withdrawal of the catheter
Suctioning the client every hour
The nurse is preparing to wean a client from a ventilator by the use of a T-piece. Which would be a component of the plan of care with this type of weaning process? Select all that apply. Pressure support is added to the oxygen system. The T-piece is connected to the client's artificial airway. The client is removed from the mechanical ventilator for a short period of time. The respiratory rate on the ventilator is gradually decreased until the client can do all of the work of breathing on their own. Supplemental oxygen is provided through the T-piece at a fraction of inspired oxygen (FiO2) that is 10% higher than a ventilator setting.
The T-piece is connected to the client's artificial airway. The client is removed from the mechanical ventilator for a short period of time. Supplemental oxygen is provided through the T-piece at a fraction of inspired oxygen (FiO2) that is 10% higher than a ventilator setting.
The nurse is changing the tracheostomy securement device on a client with a tracheostomy and is assessing the security of the ties. Which method is used to ensure that the ties are not too tightly placed? The ties leave no marks on the neck. The tracheotomy can be pulled slightly away from the neck. The nurse places 1 finger loosely between the tie and the neck. The nurse uses a 12-inch tie that is tightly affixed with hook-and-loop closures.
The nurse places 1 finger loosely between the tie and the neck .The nurse needs to assess the tracheostomy securement device to ensure that it is not too tight. The nurse ensures that there is room for 1 finger loosely or 2 fingers snugly to slide comfortably under the device. Options 1, 2, and 4 are incorrect actions.
A primary health care provider (PHCP) writes a prescription to begin to wean the client from the mechanical ventilator by use of intermittent mandatory ventilation/synchronized intermittent mandatory ventilation. The registered nurse determines that the new graduate nurse understands this modality of weaning if which statement is made? "The respiratory rate is decreased gradually until the client can assume the work of breathing without ventilatory assistance." "A T-piece will be attached to the ventilator and provide supplemental oxygen at a concentration that is 10% higher than the ventilator setting." "It will provide pressure support to decrease the workload of breathing and increase the client's ability to initiate spontaneous breathing efforts." "It involves removing the ventilator from the client and closely monitoring the client's ability to breathe spontaneously for a predetermined amount of time."
The respiratory rate is decreased gradually until the client can assume the work of breathing without ventilatory assistance."
