Week 2 Content

A client with a pulmonary embolism is being discharged home on warfarin (Coumadin). Which response suggests the client requires additional teaching about warfarin therapy by the nurse prior to discharge? 1"I will not participate in my soccer club games until I'm off the warfarin." 2"I can use a rectal suppository if I become constipated." 3"I will have to buy myself an electric shaver." 4"I will call my provider before I go to the dentist.

"I can use a rectal suppository if I become constipated."

A nurse is providing discharge instructions for a client following a tracheostomy. What statement by the client indicates a need for further instruction?

"I should apply suction while inserting the catheter into my tracheostomy"

A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best? a. "Breathing so rapidly interferes with oxygenation." b. "Maybe the client has respiratory distress syndrome." c. "The blood clot interferes with perfusion in the lungs." d. "The client needs immediate intubation and mechanical ventilation."

"The blood clot interferes with perfusion in the lungs."

Which intervention should the nurse implement first for the client diagnosed with a hemothorax who has had a right-sided chest tube for three (3) days and has no fluctu- ation (tidaling) in the water compartment? 1. Assess the client's bilateral lung sounds. 2. Obtain an order for a STAT chest x-ray. 3. Notify the health-care provider as soon as possible. 4. Document the findings in the client's chart.

***1. Assessment of the lung sounds could indi- cate that the client's lung has reexpanded because it has been three (3) days since the chest tube has been inserted.2. This should be done to ensure that the lung has reexpanded, but it is not the first intervention.3. The HCP will need to be notified so that the chest tube can be removed, but it is not the first intervention.4. This situation needs to be documented, but it is not the first intervention.TEST-TAKING HINT: When the stem asks the test taker to identify the first intervention, all four (4) answer options could be interventions that are appropriate for the situation, but only one (1) is the first intervention. Remember to apply the nursing process: the first step is assessment.

Which action should the nurse implement for the client with a hemothorax who has a right-sided chest tube and there is excessive bubbling in the water-seal compartment? 1. Check the amount of wall suction being applied. 2. Assess the tubing for any blood clots. 3. Milk the tubing proximal to distal. 4. Encourage the client to cough forcefully.

***1. Checking to see if someone has increased the suction rate is the simplest action for the nurse to implement; if it is not on high, then the nurse must check to see if the problem is with the client or the system.2. No fluctuation (tidaling) would cause the nurse to assess the tubing for a blood clot.3. The tube is milked to help dislodge a blood clot that may be blocking the chest tube causing no fluctuation (tidaling) in the water- seal compartment. The chest tube is never stripped, which creates a negative air pressure and would suck lung tissue into the chest tube.4. Encouraging the client to cough force fully will help dislodge a blood clot that may be blocking the chest tube, causing no fluctuation (tidaling) in the water-seal compartment.TEST-TAKING HINT: The test taker should always think about assessing the client if there is a problem and the client is not in immediate danger. This would cause the test taker to eliminate options "3" and "4." If the test taker thinks about bubbling, he or she should know it has to do with suctioning.

Which intervention should the nurse implement for a male client who has had a left- sided chest tube for six (6) hours and refuses to take deep breaths because it hurts too much? 1. Medicate the client and have the client take deep breaths. 2. Encourage the client to take shallow breaths to help with the pain. 3. Explain that deep breaths do not have to be taken at this time. 4. Tell the client that if he doesn't take deep breaths, he could die

***1. The client must take deep breaths to help push the air out of the pleural space into the water-seal drainage, and deep breaths will help prevent the client from develop- ing pneumonia or atelectasis.2. The client must take deep breaths; shallow breaths could lead to complications.3. Deep breaths must be taken to prevent complications.4. This is a cruel intervention; the nurse can medicate the client and then encourage deep breathing.TEST-TAKING HINT: If the test taker reads options "2" and "3" and notices that both reflect the same idea namely, that deep breaths are not necessary then both can either be eliminated as incorrect answers or kept as possible correct answers. Option "4" should be eliminated based on being a very rude and threatening comment.

The client is suspected of having a pulmonary embolus. Which diagnostic test con- firms the diagnosis? 1. Plasma D-dimer test. 2. Arterial blood gases. 3. Chest x-ray. 4. Magnetic resonance imaging (MRI).

***1. The plasma D-dimer test is highly specific for the presence of a thrombus; an elevated D-dimer indicates a thrombus formation and lysis2. ABGs evaluate oxygenation level, but they do not diagnose a pulmonary embolism.3. ACXR shows pulmonary infiltration and pleural effusions, but it does not diagnose a PE.4. MRI is a noninvasive test that detects a deep vein thrombosis, but it does not diagnose a pulmonary embolus.TEST-TAKING HINT: The keys to answering this question are the words "confirms diagnosis." The test taker should eliminate "2" and "3" based on the fact that these are diagnostic tests used for many disease processes and conditions.

Which risk factors increase a client's risk for venous thromboembolism that may progress to a pulmonary embolism? Select all that apply .1 Age 72 years 2 Admission weight of 290 lb (131.8 kg) 3 Ability to ambulate with assistance of one person 4 Presence of a central venous catheter 5 Nonsmoker

- Age 72 years -Admission weight of 290 - Presence of a central venous catheter

The nurse is assessing a client with possible pulmonary embolism (PE). For which symptoms should the nurse assess? Select all that apply .1 Dizziness and fainting 2 Shortness of breath (SOB) worsening over the last 2 weeks 3 Inspiratory chest pain 4 Productive cough 5 Pink, frothy sputum

- Dizziness and fainting - Inspiratory chest pain

A nurse is caring for a client who has a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions? 1. increase fluid intake 2. perform chest physiotherapy prior to suctioning 3. pre-lubricate the suction catheter tip with sterile saline when suctioning the airway 4. hyperventilate the client with 100% oxygen before suctioning the airway

1

The nurse determines that a client with a tracheostomy tube needs suctioning if which finding is noted? 1.Rhonchi are auscultated. 2.Pleural friction rub is heard. 3.Fine crackles are auscultated. 4.Pulse oximetry reading is 96%

1

The client had a right-sided chest tube inserted two (2) hours ago for a pneumothorax. Which action should the nurse take if there is no fluctuation (tidaling) in the water-seal compartment? 1. Obtain an order for a stat chest x-ray. 2. Increase the amount of wall suction. 3. Check the tubing for kinks or clots. 4. Monitor the client's pulse oximeter reading.

1. A STAT chest x-ray would not be needed to determine why there is no fluctuation in the water-seal compartment.2. Increasing the amount of wall suction does not address why there is no fluctuation in the water-seal compartment.***3. The key to the answer is "2 hours." The air from the pleural space is not able to get to the water-seal compartment, and the nurse should try to determine why. Usually the client is lying on the tube, it is kinked, or there is a dependent loop.4. The stem does not state that the client is in respiratory distress, and a pulse oximeter read- ing detects hypoxemia but does not address any fluctuation in the water-seal compartment.TEST-TAKING HINT: The test taker should apply the nursing process to answer the question correctly. The first step in the nursing process is assessment and "check" (option "3") is a word that can be used synonymously for assess. Monitoring (option "4") is also assess- ing, but the test taker should not check a diagnostic test result before caring for the client.

The nurse identified the client problem "decreased cardiac output" for the client diagnosed with a pulmonary embolus. Which intervention should be included in the plan of care? 1. Monitor the client's arterial blood gases. 2. Assess skin color and temperature. 3. Check the client for signs of bleeding. 4. Keep the client in the Trendelenburg position.

1. Arterial blood gases would be included in the client problem "impaired gas exchange."***2. These assessment data monitor tissue perfusion, which evaluates for decreased cardiac output. 3. This would be appropriate for the client prob- lem "high risk for bleeding."4. The client should not be put in a position with the head lower than the legs because this would increase difficulty breathing.TEST-TAKING HINT: The test taker must think about which answer option addresses the problem of not getting enough blood out of the heart. Decreased blood to the extremities results in cyanosis and cold extremities

The nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. The nurse should provide the client with which information about this type of tube? 1. Enables the client to speak 2. Prevents the client from speaking 3. Is necessary for mechanical ventilation 4. Prevents air from being inhaled through the tracheostomy opening

1. Enables the client to speak Rationale: A fenestrated tube has a small opening in the outer cannula that allows some air to escape through the larynx; this type of tube enables the client to speak. Options 2, 3, and 4 are incorrect with regard to this type of tube.

The unlicensed nursing assistant is assisting the client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention from the nurse? 1. The client's chest tube is below the level of the chest. 2. The nursing assistant has the chest tube attached to suction. 3. The nursing assistant allowed the client out of the bed .4. The nursing assistant uses a bedside commode for the client.

1. Keeping the drainage system lower than the chest promotes drainage and prevents reflux.***2. The chest tube system can function as a result of gravity and does not have to be attached to suction. Keeping it attached to suction could cause the client to trip and fall. Therefore, this is a safety issue and the nurse should intervene and explain this to the nursing assistant.3. Ambulation facilitates lung ventilation and expansion; drainage systems are portable to allow ambulation while chest tubes are in place.4. The client should ambulate, but getting up and using the bedside commode is better than stay- ing in the bed, so no action would be needed.TEST-TAKING HINT: "Warrants immediate intervention" means the test taker must identify the situation in which the nurse should intervene and correct the action, demonstrate a skill, or somehow intervene with the unlicensed assistant's behavior.

The client is getting out of bed and becomes very anxious and has a feeling of impending doom. The nurse thinks the client may be experiencing a pulmonary embolus. Which action should the nurse implement first? 1. Administer oxygen ten (10) L via nasal cannula. 2. Place the client in a high Fowler's position. 3. Obtain a STAT pulse oximeter reading. 4. Auscultate the client's lung sounds.

1. The client needs oxygen, but the nurse can do something that will help the client before applying oxygen.***2. Placing the client in this position facilitates maximal lung expansion and reduces venous return to the right side of the heart, thus lowering pressures in the pulmonary vascular system.3. This is needed, but it is not the first intervention.4. Assessing the client is indicated, but it is not the first intervention in this situation.TEST-TAKING HINT: The test taker must select the option that will directly help the client breathe easier. Therefore, assessment is not the first intervention and option "4" can be eliminated as the correct answer. Oxygenation is important but positioning the client is the easiest and first intervention. The test taker should not immediately jump to conclusions. Always read the stem and think about what will help the client.

The nurse is caring for a client with a right-sided chest tube secondary to a pneu- mothorax. Which interventions should the nurse implement when caring for this client? Select all that apply. 1. Place the client in a low-Fowler's position. 2. Assess chest tube drainage system frequently. 3. Maintain strict bed rest for the client. 4. Secure a loop of drainage tubing to the sheet. 5. Observe the site for subcutaneous emphysema.

1. The client should be in a high-Fowler's posi- tion to facilitate lung expansion.***2. The system must be patent and intact to function properly.3. The client can have bathroom privileges, and ambulation facilitates lung ventilation and expansion.***4. Looping the tubing prevents direct pres- sure on the chest tube itself and keeps tubing off the floor, addressing both a safety and an infection control issue.***5. Subcutaneous emphysema is air under the skin, which is a common occurrence at the chest tube insertion site.TEST-TAKING HINT: The test taker should be careful with adjectives. In option "1" the word "low" makes it incorrect; in option "3," the word "strict" makes this option incorrect.

Which statement by the client indicates the discharge teaching for the client diagnosed with a pulmonary embolus is effective? 1. "I am going to use a regular-bristle toothbrush." 2. "I will take antibiotics prior to having my teeth cleaned." 3. "I can take enteric-coated aspirin for my headache." 4. "I will wear a medic alert band at all times."

1. The client should use a soft-bristle toothbrush to reduce the risk of bleeding.2. This is appropriate for a client with a mechan- ical valve replacement, not a client receiving anticoagulant therapy.3. Aspirin, enteric-coated or not, is an anti- platelet, which may increase bleeding tendencies and should be avoided.***4. The client should wear a medic alert band at all times so that if any accident or situation occurs, the health-care providers will know the client is receiving anticoagulant therapy.TEST-TAKING HINT: This is a higher-level ques- tion in which the test taker must know that a client with a pulmonary embolus would be prescribed anticoagulant therapy on discharge from the hospital. If the test taker had no idea of the answer, however, the option stating "wear a medic alert band" would be a good choice because many disease

The client is admitted to the emergency department with chest trauma. When assess- ing the client, which signs/symptoms would the nurse expect to find that support the diagnosis of pneumothorax? 1. Bronchovesicular lung sounds and bradypnea. 2. Unequal lung expansion and dyspnea. 3. Frothy bloody sputum and consolidation. 4. Barrel chest and polycythemia.

1. The client with pneumothorax would have absent breath sounds and tachypnea.***2. Unequal lung expansion and dyspnea would indicate a pneumothorax.3. Consolidation occurs when there is no air moving through the alveoli as in pneumonia; frothy sputum occurs with congestive heart failure.4. Barrel chest and polycythemia are signs of chronic obstructive pulmonary disease.TEST-TAKING HINT: The test taker can use "chest trauma" or "pneumothorax" to help select the correct answer. Both of these words should cause the test taker to select "2" because unequal chest expansion would result from trauma.

The nurse is preparing to administer the oral anticoagulant warfarin (Coumadin) to a client who has a PT/PTT of 22/39 and an INR 2.8. What action should the nurse implement? 1. Assess the client for abnormal bleeding. 2. Prepare to administer vitamin K (AquaMephyton). 3. Administer the medication as ordered. 4. Notify the HCP to obtain an order to increase the dose.

1. The client would not be experiencing abnor- mal bleeding with this INR.2. This is the antidote for an overdose of antico- agulant and the INR does not indicate this.***3. A therapeutic INR is 2-3; therefore, the nurse should administer the medication.4. There is no need to increase the dose; this result is within the therapeutic range.TEST-TAKING HINT: The test taker must know normal laboratory values; this is the only way the test taker will be able to answer this question. The test taker should make a list of laboratory values that must be memorized for successful test taking.

The client has a right-sided chest tube. As the client is getting out of the bed it is acci- dentally pulled out of the pleural space. Which action should the nurse implement first? 1. Notify the health-care provider to have chest tubes reinserted STAT. 2. Instruct the client to take slow shallow breaths until the tube is reinserted. 3. Take no action and assess the client's respiratory status every 15 minutes. 4. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site.

1. The health-care provider will have to be noti- fied, but this is not the first intervention. Air must be prevented from entering the pleural space from the outside atmosphere.2. The client should breathe regularly or take deep breaths until the tubes are reinserted.3. The nurse must take action and prevent air from entering the pleural space.***4. Taping on three sides prevents the development of a tension pneumothorax by inhibiting air from entering the wound during inhalation but allowing it to escape during exhalation.TEST-TAKING HINT: The word "first interven- tion" in the stem of the question indicates to the test taker that possibly more than one (1) intervention could be indicated in the situa- tion but only one (1) is implemented first. Remember, do not select assessment first without reading the question. If the client is in any type of crisis, then the nurse should first do something to help the client's situation

The client has just been diagnosed with a pulmonary embolus. Which intervention should the nurse implement? 1. Administer oral anticoagulants 2. Assess the client's bowel sounds 3. Prepare the client for a thoracentesis. 4. Institute and maintain bed rest.

1. The intravenous anticoagulant heparin will be administered immediately after diagnosis of a PE, not oral anticoagulants.2. The client's respiratory system will be assessed, not the gastrointestinal system.3. A thoracentesis is used to aspirate fluid from the pleural space; it is not a treatment for a PE.***4. Bed rest reduces metabolic demands and tissue needs for oxygen.TEST-TAKING HINT: The test taker must be aware of adjectives such as "oral" in option "1," which make this option incorrect. The test taker should apply the body system of the disease process to eliminate "2" as a correct answer.

The alert and oriented client is diagnosed with a spontaneous pneumothorax, and the physician is preparing to insert a left-sided chest tube. Which intervention should the nurse implement first? 1. Gather the needed supplies for the procedure. 2. Obtain a signed informed consent form. 3. Assist the client into a side-lying position. 4. Discuss the procedure with the client.

1. The nurse should gather a thoracotomy tray and the chest tube drainage system and take it to the client's bedside, but it is not the first intervention. ***2. The insertion of a chest tube is an invasive procedure and so requires informed con- sent. Without a consent form, this procedure cannot be done on an alert and oriented client.3. This is a correct position to place the client for a chest tube insertion, but it is not the first intervention.4. The physician will discuss the procedure withthe client, then informed consent must be obtained, and then the nurse can do further teaching.TEST-TAKING HINT: The test taker must know that invasive procedures require informed consent and legally it must be obtained first before anyone can touch the client.

Which assessment data would support that the client has experienced a pulmonary embolus?1. Calf pain with dorsiflexion of the foot. 2. Sudden onset of chest pain and dyspnea. 3. Left-sided chest pain and diaphoresis. 4. Bilateral crackles and low-grade fever.

1. This is a sign of a deep vein thrombosis, which is a precursor to a PE, but it is not a sign of a pulmonary embolism.***2. The most common signs of a PE are sudden onset of chest pain when taking a deep breath and shortness of breath.3. These are signs of a myocardial infarction.4. These could be signs of pneumonia or other pulmonary complications, but not specifically a PE.TEST-TAKING HINT: The key to selecting "2" as the correct answer is sudden onset. The test taker would need to note "left-sided" in "3" to eliminate this as a possible correct answer, and "4" is nonspecific for a PE.

Which assessment data indicate that the chest tubes have been effective in treating the client with a hemothorax who has a right-sided chest tube? 1. There is gentle bubbling in the suction compartment. 2. There is no fluctuation (tidaling) in the water-seal compartment. 3. There is 250 mL of blood in the drainage compartment 4. The client is able to deep breathe without any pain.

1. This is an expected finding in the suction compartment of the drainage system that indicates adequate suctioning is being applied.***2. At three (3) days post-insertion, no fluctuation (tidaling) indicates the lung has reexpanded, which indicates the treatment has been effective. 3. Blood in the drainage bottle is expected for a hemothorax but does not indicate the chest tubes have reexpanded the lung4. Taking a deep breath without pain is good, but it does not mean the lungs have reexpanded.TEST-TAKING HINT: The test taker must be knowledgeable about chest tubes to be able to answer this question. The test taker must know the normal time frame and what is expected for each compartment of the chest tube drainage system.

The nurse is presenting a class on chest tubes. Which statement describes a tension pneumothorax?1. A tension pneumothorax develops when an air-filled bleb on the surface of the lung ruptures. 2. When a tension pneumothorax occurs, the air moves freely between the pleural space and the atmosphere. 3. The injury allows air into the pleural space but prevents it from escaping from the pleural space. 4. A tension pneumothorax results from a puncture of the pleura during a central line placement.

1. This is incorrect information. It is the description of a spontaneous pneumothorax.2. This is the description of an open pneumothorax.***3. This describes a tension pneumothorax. It is a medical emergency requiring immediate intervention to preserve life.4. This is called an iatrogenic pneumothorax, which also may be caused by thoracentesis or lung biopsy. A tension pneumothorax could occur from this procedure, but it does not describe a tension pneumothorax.TEST-TAKING HINT: The test taker must always be clear about what the question is asking before answering the question. If the test taker can eliminate options "1" and "2" and can't decide between "3" and "4," the test taker must go back to the stem and clarify what the question is asking.

The nurse is planning to suction a client through a tracheostomy tube. Which is the amount of time for application of suction during withdrawal of the catheter? 1. 10 seconds 2. 25 seconds 3. 30 seconds 4. 35 seconds

10 seconds

A client has chest tubes attached to a chest-tube drainage system. What should the nurse do when caring for this client? 1. Clamp the chest tubes when suctioning. 2. Palpate the surrounding area for crepitus. 3. Change the dressing daily using aseptic technique. 4. Empty the drainage chamber at the end of the shift.

2

A nurse is caring for a client who is 1 day postop following a left lower lung lobectomy. When checking the client's closed chest drainage system, the nurse notes that there is no bubbling in the suction control chamber. The nurse should 1. notify the provider 2. verify that the suction regulator is on 3. continue to monitor the client as this is an expected finding 4. milk the chest tube to dislodge any clots in the tubing that may be occluding it

2

he client is returned to the nursing unit following thoracic surgery with a chest tube in place. During the first few hours postoperatively, the nurse assesses for drainage and expects to note which characteristics? 1.The drainage is serous. 2.The drainage is bloody. 3.The drainage is serosanguineous. 4.The drainage is bloody, with frequent small clots

2

he nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal compartment. Which is the most appropriateaction? 1.Check for an air leak. 2.Document the findings. 3.Notify the health care provider (HCP). 4.Change the chest tube drainage system.

2

The nurse is preparing to suction an adult client through the client's tracheostomy tube. Which interventions should the nurse perform for this procedure? Select all that apply .1. Apply suction for up to 10 to 15 seconds. 2. Hyperoxygenate the client before suctioning. 3. Set the wall suction unit pressure at 160 mm Hg. 4. Apply suction while gently inserting the catheter. 5. Apply intermittent suction while rotating and withdrawing the catheter. 6. Advance the catheter until resistance is met and then pull the catheter back 1 cm.

2,5,6

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? 1. Suctioning is required frequently. 2. Aspiration of gastric contents occurs when suctioning. 3. The client's skin and mucous membranes are light pink. 4. Excessive secretions are suctioned from a tracheostomy

2. Aspiration of gastric contents occurs when suctioning.

The nurse is assisting in caring for a client with a newly inserted tracheostomy. The nurse notes documentation of an airway problem because of thick respiratory secretions. The nurse should monitor for which item as the best indicator of an adequate respiratory status? 1. Oxygen saturation of 89% 2. Respiratory rate of 18 breaths per minute 3. Moderate amounts of tracheobronchial secretions 4. Small to moderate amounts of frank blood suctioned from the tube

2. Respiratory rate of 18 breaths per minute

Which client has the highest risk for developing a pulmonary embolism (PE)? 1.25-year-old woman who frequently flies to different countries 2.67-year-old man who works on a farm 3.45-year-old man admitted for a heart attack 4.23-year-old woman with a bleeding disorder

25 year old woman who frequently flies to different countries

A health care provider (HCP) is about to remove a chest tube from a client. After the dressing is removed and the sutures have been cut, the nurse assisting the health care provider should ask the client to perform which procedure? 1.Take a deep breath. 2.Exhale immediately. 3.Breathe in and out quickly. 4.Take a deep breath and hold it

4

The nurse has completed care for a client whose tracheostomy tube has a nondisposable inner cannula. Which action should the nurse perform prior to reinserting the inner cannula? 1.Suction the client's airway. 2.Wipe the inner cannula off with a clean washcloth. 3.Dry the inner cannula thoroughly with sterile gauze. 4.Allow the inner cannula to dry after washing it with sterile water.

4

A client attached to mechanical ventilation suddenly becomes restless and pulls out the tracheostomy tube. Which is the nurse's priority intervention? 1. Prepare for reintubation. 2. Call the health care provider. 3. Call the rapid response team. 4. Check the client for spontaneous breathing.

4. Check the client for spontaneous breathing.

The nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes the presence of an audible wheeze. The nurse attempts to remove the suction catheter from the client's trachea but is unable to do so. What is the nurse's priority response? 1. Call a code. 2. Administer a bronchodilator. 3. Contact the health care provider. 4. Disconnect the suction source from the catheter.

4. Disconnect the suction source from the catheter.

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. The nurse should determine that a. the lung has fully expanded b. the lung has collapsed c. the chest tube is in the pleural space d. the mediastinal space has decreased

A

A client has been admitted with chest trauma after a motor vehicle crash and has undergone intubation. The nurse checks on the client when the high pressure alarm 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? a. right pneumothorax b. pulmonary embolism c. displaced endotracheal tube d. acute respiratory distress syndrome

A

A client has been in an automobile accident, and the nurse is assessing the client for possible pneumothorax. The nurse should assess the client for a. sudden, sharp chest pain b. wheezing breath sounds over the affected side c. hemoptysis d. cyanosis

A

A female client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism? a. Dyspnea b. Bradypnea c. Bradycardia d. Decreased respiratory

A

A patient experiences a steering wheel injury as a result of an automobile accident. During the initial assessment, the emergency department nurse would be most concerned about a. paradoxic chest movement. b. the complaint of chest wall pain. c. a heart rate of 110 beats/minute. d. a large bruised area on the chest.

A

A patient has a tracheostomy that is 3 days old. Upon assessment, the nurse notes that the patient's face is puffy and the eyelids are swollen. What action by the nurse takes priority? A. Assess the patient's oxygen saturation. B. Notify the Rapid Response Team. C. Oxygenate the patient with a bag-valve-mask. D. Palpate the skin of the upper chest.

A

A patient is admitted to the emergency department complaining of sudden onset shortness of breath and is diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing to confirm the diagnosis? a. Start an IV so contrast media may be given. b. Ensure that the patient has been NPO for at least 6 hours. c. Inform radiology that radioactive glucose preparation is needed. d. Instruct the patient to undress to the waist and remove any metal objects.

A

A patient with a gunshot wound to the right side of the chest arrives in the emergency department exhibiting severe shortness of breath with decreased breath sounds on the right side of the chest. Which action should the nurse take immediately? a. Cover the chest wound with a nonporous dressing taped on three sides. b. Pack the chest wound with sterile saline soaked gauze and tape securely. c. Stabilize the chest wall with tape and initiate positive pressure ventilation. d. Apply a pressure dressing over the wound to prevent excessive loss of blood.

A

A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142, BP reading of 100/60, and respirations of 42. The nurses first action should be to a. elevate the head of the bed to 45 to 60 degrees. b. administer the ordered pain medication. c. notify the patients health care provider. d. offer emotional support and reassurance.

A

A patient with an opening in the chest wall, such as from a gunshot, stab wound or impalement, resulting in "sucking chest wound" can be said to have: A. An open pneumothorax B. A closed pneumothorax C. A hemothorax D. A pleural effusion

A

A priority nursing intervention for a patient who has just undergone a chemical pleurodesis for recurrent pleural effusion is a. administering ordered analgesia b. monitoring chest tube drainage c. sending pleural fluid for laboratory analysis d. monitoring the patient's level of consciousness

A

An hour after a thoracotomy, a patient complains of incisional pain at a level 7 out of 10 and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next? a. Administer the prescribed PRN morphine. b. Assist the patient to deep breathe and cough. c. Milk the chest tube gently to remove any clots. d. Tape the area around the insertion site of the chest tube.

A

An unlicensed assistive personnel (UAP) was feeding a patient with a tracheostomy. Later that evening, the UAP reports that the patient had a coughing spell during the meal. What action by the nurse takes priority? A. Assess the patient's lung sounds. B. Assign a different UAP to the patient. C. Report the UAP to the manager. D. Request thicker liquids for meals.

A

If the chest tube is pulled out of the patient's chest, and the patient had an air leak from the lung, after asking a colleague to call a physician STAT, emergency nursing management is to: A. Cover the opening with a sterile dressing, taped on three sides B. Cover the opening with a sterile Vaseline gauze, taped securely on all sides C. Leave the opening alone and monitor the patient until a physician can assess the situation D. Try to put the tube back in place as quickly as possible

A

The nurse is admitting a patient for whom a diagnosis of pulmonary embolus must be ruled out. The patient's history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolus? a. The patient was recently in a motor vehicle crash. b. The patient participated in an aerobic exercise program for 6 months. c. The patient gave birth to her youngest child 1 year ago. d. The patient was on bed rest for 6 hours after a diagnostic procedure.

A

The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would determine if the cuff has been properly inflated? a. Use a hand-held manometer to measure cuff pressure. b. Review the health record for the prescribed cuff pressure. c. Suction the patient through a fenestrated inner cannula to clear secretions. d. Insert the decannulation plug before removing the nonfenestrated inner cannula.

A

The nurse notes tidaling of the water level in the tube submerged in the water-seal chamber in a patient with a closed chest tube drainage. The nurse should a. continue to monitor the patient b. check all connections for a leak in the system c. lower the drainage collector further from the chest d. clamp the tubing at progressively distal points away from the patient until the tidaling stops

A

When is it beneficial to clamp a patient's chest tube? A. When ordered by a physician to simulate tube removal and assess the patient's response B. Whenever a patient leaves the nursing unit and cannot be monitored C. When ambulating a postoperative patient with a chest tube D. It is never beneficial to clamp a patient's chest tube

A

When should the nurse check for leaks in the chest tube and pleural drainage system? a. there is continuous bubbling in the water-seal chamber b. there is constant bubbling of water in the suction control chamber c. fluid in the water seal chamber fluctuates with the patient's breathing d. the water levels in the water seal and suction control chambers are decreased

A

Which intervention will be most effective in reducing anxiety in the client with a pulmonary embolism (PE)? A. Remain with the client, and provide oxygen in a calm manner. B. Have the client breathe into a brown paper bag using pursed lips. C. Offer the client a mild sedative. D. Allow a family member to remain in the room

A

A nurse is caring for four clients. What client is at greatest risk for pulmonary embolism?

A client who is 12hr postop following a total hip arthroplasty

A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client's room? (Select all that apply) a. oxygen b. sterile water c. enclosed hemostat clamps d. indwelling urinary catheter e. occlusive dressing

A,B,C,E

A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? Select all that apply a. encourage the client to cough and deep breathe b. check for continuous bubbling in the suction chamber c. strip the drainage tubing every 4 hours d. clamp the tube once a day e. obtain a chest x-ray

A,B,E

The nurse is admitting a patient with a diagnosis of pulmonary embolism. What risk factors is a priority for the nurse to assess? Select all that apply a. Obesity b. Pneumonia c. Malignancy d. Cigarette smoking e. Prolonged air travel

A,C,D,E

A nurse is caring for a patient who has a tracheostomy tube. What actions may the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) A. Applying water-soluble lip balm to the patient's lips B. Ensuring that the humidification provided is adequate C. Performing oral care with alcohol-based mouthwash D. Reminding the patient to cough and deep breathe often E. Suctioning excess secretions through the tracheostomy

A,D

A patient is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the patient maintain self-esteem? (Select all that apply.) A. Create a communication system. B. Don't go out in public alone. C. Find hobbies to enjoy at home. D. Try loose-fitting shirts with collars.E. Wear fashionable scarves.

A,D,E

A patient with an uncuffed tracheostomy tube coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first? a. Insert the obturator and attempt to reinsert the tracheostomy tube. b. Position the patient in an upright position with the neck extended. c. Assess the patient's oxygen saturation and notify the health care provider. d. Ventilate the patient with a manual bag until the health care provider arrives.

ANS: A The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient's airway. Assessing the patient's oxygenation is an important action, but it is not the most appropriate first action in this situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. The patient should be placed in a semi-Fowler's position if reinsertion of the tracheostomy tube is not successful.

When inflating the cuff on a tracheostomy tube to the appropriate level, the best action by the nurse will be to a. check the pilot balloon after inflation to ensure that it is firm. b. use a manometer to ensure cuff pressure is at an appropriate level .c. check the amount of cuff pressure ordered by the health care provider. d. fill the balloon until minimal air leakage around the cuff is auscultated.

ANS: B Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20 mm Hg or lower will avoid compression of the tracheal capillaries. A firm pilot balloon indicates that the cuff is inflated but does not assess for overinflation. A health care provider's order is not required to determine safe cuff pressure. A minimal leak technique is an alternate means for cuff inflation, but this technique does allow a small air leak around the cuff and increases the risk for aspiration.

An RN is observing a nursing student who is suctioning a hospitalized patient with a tracheostomy in place. Which action by the student requires the RN to intervene? a. The student preoxygenates the patient for 1 minute before suctioning. b. The student puts on clean gloves and uses a sterile catheter to suction. c. The student inserts the catheter about 5 inches into the tracheostomy tube. d. The student applies suction for 10 seconds while withdrawing the catheter.

ANS: B Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. The other student actions do not require intervention by the RN. Although the patient may not need 1 minute of preoxygenation, this would not be unsafe. Suctioning for 10 seconds is appropriate. The length of catheter that should be inserted depends on the length of the tracheostomy tube, but 5 inches would be appropriate for most adult patients.

A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply.) a.Production of pink sputum b.Tracheal deviation c.Sudden onset of shortness of breath d.Pain at insertion sitee.Drainage of 75 mL/hr

ANS: B, C

The nurse is caring for a spontaneously breathing patient who has a tracheostomy. To determine that the patient can protect the airway when eating without having the tracheostomy cuff inflated, the nurse will deflate the cuff and a. ask the patient to say a few sentences. b. monitor for signs of respiratory distress. c. have the patient drink a small amount of grape juice and observe for coughing. d. auscultate the lungs for crackles after having the patient take a few sips of water.

ANS: C Because the cuff is deflated when using a fenestrated tube, the patient's risk for aspiration should be assessed before changing to a fenestrated tracheostomy tube. The decannulation cap is never inserted before cuff deflation because to do so would obstruct the patient's airway. The cuff is deflated and the inner cannula removed to allow air to flow across the patient's vocal cords when using a fenestrated tube.

When the nurse is deflating the cuff of a tracheostomy tube to evaluate the patient's ability to swallow, it is important to a. clean the inner cannula of the tracheostomy tube before deflation. b. deflate the cuff during the inhalation phase of the respiratory cycle. c. suction the patient's mouth and trachea before deflation of the cuff. d. insert exactly the same volume of air into the cuff during reinflation.

ANS: C The patient's mouth and trachea should be suctioned before the cuff is deflated to prevent aspiration of oral secretions. The amount of air needed to inflate the cuff varies and is adjusted by measuring cuff pressure or using the minimal leak technique, not by measuring the volume of air removed from the cuff. The cuff is deflated during patient exhalation so that secretions will be forced into the mouth rather than aspirated. There is no need to clean the inner cannula before cuff deflation.

The nurse is caring for a client at home who has had a tracheostomy tube for several months. The nurse monitors the client for complications associated with the long-term tracheostomy and suspects tracheoesophageal fistula if which observation is noted for the client? 1. Abdominal distention 2. Purulent drainage around the tracheotomy site 3. Excessive secretions from the tracheotomy site 4. Inability to pass a suction catheter through the tracheotomy

Abdominal distention

A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.) a. Acknowledge the frightening nature of the illness. b. Delegate a back rub to the unlicensed assistive personnel (UAP). c. Give simple explanations of what is happening. d. Request a prescription for antianxiety medication. e. Stay with the client and speak in a quiet, calm voice.

Acknowledge the frightening nature of the illness Delegate a back rub to the unlicensed assistive personnel (UAP) Give simple explanations of what is happening. Stay with the client and speak in a quiet, calm voice.

A nurse is caring for a client who has pulmonary embolism. Which of the following interventions is the priority?

Administer heparin via continuous IV infusion.

A client who has a venous thromboembolism in the upper arm is to be started on oral warfarin (Coumadin) while still receiving an intravenous heparin infusion. What is the nurse's best action? 1Administer the medications as prescribed. 2Clarify the warfarin and heparin orders with the provider. 3Hold the dose of warfarin until the client's partial thromboplastin time (PTT) is within normal range .4Place the client on a bed alarm as a safety precaution.

Administer the medications as prescribed

A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care? a. Airway protection b. Decreasing intracranial pressure c. Stabilizing cardiac arrhythmias d. Preventing musculoskeletal disability

Airway protection

A client in the emergency department has several broken ribs. What care measure will best promote comfort? a. Allowing the client to choose the position in bed b. Humidifying the supplemental oxygen c. Offering frequent, small drinks of water d. Providing warmed blankets

Allowing the client to choose the position in bed

A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority? a. Alteplase (Activase) b. Enoxaparin (Lovenox) c. Unfractionated heparin d. Warfarin sodium (Coumadin)

Alteplase (Activase)

A client receiving intravenous alteplase (tPA) after developing a pulmonary embolism develops bloody stools and bleeding gums. The nurse notifies the provider and obtains an order for which antidote? 1Aminocaproic acid (Amicar) 2Packed red blood cells 3Phytonadione (AquaMEPHYTON) 4Protamine sulfate

Aminocaproic acid (Amicar)

A client has been diagnosed with an empyema. What interventions should the nurse anticipate providing to this client? (Select all that apply.)

Assisting with chest tube insertion Facilitating pleural fluid sampling Performing frequent respiratory assessment Providing antipyretics as needed

A nurse is assisting the provider to care for a client who has developed a spontaneous pneumothorax. Which of the following actions should the nurse perform first? a. assess the client's pain b. obtain a large-bore IV needle for decompression c. administer lorazepam d. prepare for chest tube insertion

B

A nurse is caring for a client who has a chest tube and a drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first? a. obtain a chest x-ray b. apply sterile gauze to the insertion site c. place tape around the insertion site d. assess respiratory status

B

A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse? a. "I am allergic to morphine" b. "I take antacids several times a day for my ulcer" c. "I had a blood clot in my leg several years ago" d. "It hurts to take a deep breath"

B

A patient has a tracheostomy tube in place. When the nurse suctions the patient, food particles are noted. What action by the nurse is best? A. Elevate the head of the patient's bed. B. Measure and compare cuff pressures. C. Place the patient on NPO status. D. Request that the patient have a swallow study.

B

A patient is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority? A. Administer prescribed anxiolytic medication. B. Ensure that informed consent is on the chart. C. Reinforce any teaching done previously. D. Start the preoperative antibiotic infusion.

B

An emergency room nurse is assessing a female client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client? a. A low respiratory b. Diminished breathe sounds c. The presence of a barrel chest d. A sucking sound at the site of injury

B

The client has been admitted for a pulmonary embolism and is receiving heparin infusion. What safety priority does the nurse include in the plan of care? A. Teach the client to avoid using dental floss. B. Monitor the platelet count daily. C. Ensure adequate staffing for the unit. D. Notify radiology of an impending scan.

B

The following would result in a loss of the water seal: A. Momentary tipping-over of the Atrium drainage system. B. Evaporation of the water in the water seal chamber below the 2 cm mark. C. Suction removed or turned off .D. The drainage chambers are full.

B

The nurse caring for a male client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to: a. Call the physician .b. Place the tube in a bottle of sterile water. c. Immediately replace the chest tube system. d. Place the sterile dressing over the disconnection site.

B

The nurse instructs a patient with a pulmonary embolism about administering enoxaparin after discharge. Which statement by the patient indicates understanding about the instructions? a. "I need to take this medicine with meals." b. "The medicine will be prescribed for 10 days." c. "I will inject this medicine into my upper arm." d. "The medicine will dissolve the clot in my lung."

B

The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would the nurse clearly instruct the nursing student to report immediately? a. Chest tube drainage of 10 to 15 mL/hr b. Continuous bubbling in the water-seal chamber c. Reports of pain at the chest tube site d. Chest tube dressing dated yesterday

B

The nurse observes a constant gentle bubbling in the water seal column of a water seal chest drainage system. The nurse should a. continue monitoring as usual; this is expected b. check the connectors between the chest and drainage tubes and where the drainage tube enters the chest drainage system c. decrease the suction and continue observing the system for changes in bubbling during the next several hours d. notify the healthcare provider

B

To determine whether a tension pneumothorax is developing in a patient with chest trauma, for what does the nurse assess the patient? a. dull percussion sounds on the injured side b. severe respiratory distress and tracheal deviation c. muffled and distant heart sounds with decreasing blood pressure d. decreased movement and diminished breath sounds on the affected side

B

When planning care for a patient at risk for pulmonary embolism, the nurse prioritizes a. maintaining the patient on bed rest b. using sequential compression devices c. encouraging the patient to cough and deep breathe d. teaching the patient how to use the incentive spirometer

B

Which of the following situations is likely to result in an absence of fluctuations in the chest drainage tubing? A. The tubing is coiled on the bed with a straight path to the chest drain B. The tubing is blocked in some way C. The patient is receiving positive pressure ventilation D. The patient is ambulatory

B

Which of these nursing actions can the RN working in a long-term care facility delegate to an experienced LPN/LVN who is caring for a patient with a permanent tracheostomy? a. Assessing the patient's risk for aspiration b. Suctioning the tracheostomy when needed c. Educating the patient about self-care of the tracheostomy d. Determining the need for replacement of the tracheostomy tube

B

While changing the tapes on a tracheostomy tube, the male client coughs and the tube is dislodged. The initial nursing action is to: a. Call the physician to reinsert the tube. b. Grasp the retention sutures to spread the opening. c. Call the respiratory therapy department to reinsert the tracheotomy. d. Cover the tracheostomy site with a sterile dressing to prevent infection.

B

A patient whose tracheostomy was inserted 30 minutes ago is recovering in the postanesthesia recovery unit when he coughs and expels the tracheostomy tube. How should the nurse respond? A.Suction the tracheostomy opening. B.Maintain the airway with a sterile hemostat. C.Use an Ambu bag and mask to ventilate the patient. D.Insert the tracheostomy tube obturator into the stoma.

B As long as the patient is not in acute respiratory distress after dislodging the tracheostomy tube, the nurse should use a sterile hemostat to maintain an open airway until a sterile tracheostomy tube can be reinserted into the tracheal opening. The tracheostomy is an open surgical wound that has not had time to mature into a stoma. If the patient is in respiratory distress, the nurse will use an Ambu bag and mask to ventilate the patient temporarily.

When caring for a client with pulmonary embolism, which blood gas result does the nurse anticipate early in the course of the disease? A. pH 7.24, PCO2 55, HCO 26, PO2 56 B. pH 7.46, PCO2 30, HCO 26, PO2 68 C. pH 7.35, PCO2 45, HCO 24, PO2 80 D. pH 7.47, PCO2 35, HCO 30, PO2 75

B) Hyperventilation triggered by hypoxia and pain first leads to respiratory alkalosis, indicated by low partial pressure of arterial carbon dioxide (Paco2) and high pH. No compensation is present as the HCO3 is normal, and hypoxemia is present, consistent with PE.

A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? Select all that apply a. continuous bubbling in the water seal chamber b. gentle constant bubbling in the suction control chamber c. rise and fall in level of water in water seal chamber with inspiration and expiration d. exposed sutures without dressing e. drainage system upright at chest level

B,C

A nurse in the ED is assessing a client who has sustained multiple rib fractures and has a flail chest. Which of the following findings should the nurse expect? Select all that apply a. bradycardia b. cyanosis c. hypotension d. dyspnea e. paradoxical chest movement

B,C,D,E

A nurse is assessing a client who has a pulmonary embolism. Which of the following manifestations should the nurse expect? Select all that apply a. bradypnea b. pleural friction rub c. hypertension d. petechiae e. tachycardia

B,D,E

Which task can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) in the care of a stable patient who has a tracheostomy? A.Assessing the need for suctioning B.Suctioning the patient's oropharynx C.Assessing the patient's swallowing ability D.Maintaining appropriate cuff inflation pressure

B. Providing the individual has been trained in correct technique, UAP may suction the patient's oropharynx. Assessing the need for suctioning should be performed by an RN or licensed practical nurse, whereas swallowing assessment and the maintenance of cuff inflation pressure should be performed solely by the RN.

If a pleural effusion develops, which of the following actions best describes how the fluid can be removed from the pleural space and proper lung status restored? A. Inserting a chest tube B. Performing thoracentesis C. Performing paracentesis D. Allowing the pleural effusion to drain by itself

B. Performing thoracentesis Performing thoracentesis is used to remove excess pleural fluid.

A UAP is taking care of a patient with a chest tube. The nurse should intervene when she observes the UAP a. looping the drainage tubing on the bed b. securing the drainage container in an upright position c. stripping or milking the chest tube to promote drainage d. reminding the patient to cough and deep breathe every 2 hours

C

A nurse should interpret which finding as an early sign of a tension penumothorax in a client with chest trauma? a. diminished bilateral breath sounds b. muffled heart sounds c. respiratory distress d. tracheal deviation

C

A patient is admitted to the emergency department with an open stab wound to the right chest. What is the first action that the nurse should take? a. Position the patient so that the right chest is dependent. b. Keep the head of the patients bed at no more than 30 degrees elevation. c. Tape a nonporous dressing on three sides over the chest wound. d. Cover the sucking chest wound firmly with an occlusive dressing.

C

A pulmonary embolus is suspected in a patient with a DVT who develops dyspnea, tachycardia, and chest pain. Diagnostic testing is scheduled. Which test should the nurse plan to teach the patient about? a. D-dimer b. chest x-ray c. spiral (helical) CT scan d. ventilation-perfusion lung scan

C

A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor? A. Holding the device securely when changing ties B. Suctioning the patient first if secretions are present C. Tying a square knot at the back of the neck D. Using half-strength peroxide for cleansing

C

One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing actions? a. Water-seal chamber has 5 cm of water. b. No new drainage in collection chamber c. Chest tube with a loose-fitting dressing d. Small pneumothorax at CT insertion site

C

The nurse has just finished assisting the health care provider with a thoracentesis for a patient with recurrent left pleural effusion caused by lung cancer. The thoracentesis removed 1800 mL of fluid. Which patient assessment information is most important to report to the health care provider (HCP)? a. The patient starts crying and says she can't go on with treatment much longer. b. The patient reports sharp, stabbing chest pain with every deep breath. c. The blood pressure is 100/48 mm Hg, and the heart rate is 102 beats/min. d. The dressing at the thoracentesis site has 1 cm of bloody drainage.

C

The nurse identifies a flail chest in a trauma patient when a. multiple rib fractures are determined by x-ray b. a tracheal deviation to the unaffected side is present c. paradoxical chest movement occurs during respiration d. there is decreased movement of the involved chest wall

C

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first? a.Assist the patient to sit upright in a chair. b.Splint the patient's chest during coughing. c.Medicate the patient with prescribed morphine. d.Observe the patient use the incentive spirometer.

C

The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung. Which information should the nurse include about the patient's postoperative care? a.Positioning on the right side b.Bed rest for the first 24 hours c.Frequent use of an incentive spirometer d.Chest tube placement with continuous drainage

C

The water seal is the most important element of the drainage system because: A. It indicates patency of the tubing by tidaling with inspiration and expiration B. It allows air to enter the pleural space but prevent air from exiting the pleural space through the chest tube C. It allows air to exit the pleural space but prevent air from entering the pleural space through the chest tube D. It allows air to move freely in and out of the pleural space through the chest tube.

C

Which of the following signs indicates a chest tube may be removed? A. Drainage is approximately 100mL/hr in a patient with pleural chest tube following spinal surgery B. The chest radiograph shows only a small residual pneumothorax in a patient requiring mechanical ventilation C. Bubbling in the water seal has been absent for 24 hours following iatrogenic pneumothorax from CVP placement D. Fluctuations in the water seal are approximately 2 to 4cmH2O with each breathing cycle

C

While assessing a thoracotomy incisional area from which a chest tube exits, the nurse feels a crackling sensation under the fingertips along the entire incision. What should the nurse do next? a. lower the head of bed, and call the HCP b. prepare an aspiration tray c. mark the area with a skin pencil at the outer periphery of the crackling d. turn off the suction of the chest drainage

C

Which nursing action would e of highest priority when suctioning a patient with a tracheostomy? a. Auscultating lung sounds after suctioning is complete. b. Providing a means of communication for the patient during the procedure. c. Assessing the patient's oxygenation saturation before, during and after suctioning. d. Administering pain and/or antianxiety medication 30 minutes before suctioning.

C Rationale: A patient with a tracheostomy is at risk for hypoxemia after suctioning. Therefore, it is imperative to monitor the patient's oxygen status before, during, and after suctioning. Remember the protocol for airway, breathing, and circulation (ABCs) when prioritizing.

What is the priority nursing assessment in the care of a patient who has a tracheostomy? A.Electrolyte levels and daily weights B.Assessment of speech and swallowing C.Respiratory rate and oxygen saturation D.Pain assessment and assessment of mobility

C The priority assessment in the care of a patient with a tracheostomy focuses on airway and breathing. These assessments supersede the nurse's assessments that may also be necessary, such as nutritional status, speech, pain, and swallowing ability.

Which of the following treatments would the nurse expect for a client with a spontaneous pneumothorax?A. Antibiotics B. Bronchodilators C. Chest tube placement D. Hyperbaric chamber

C. Chest tube placement The only way to re-expand the lung is to place a chest tube on the right side so the air in the pleural space can be removed & the lung re-expanded.

Which of the following methods is the best way to confirm the diagnosis of a pneumothorax? A. Auscultate breath sounds B. Have the client use an incentive spirometer C. Take a chest x-ray D. Stick a needle in the area of decreased breath sounds

C. Take a chest x-ray A chest x-ray will show the area of collapsed lung if pneumothorax is present as well as the volume of air in the pleural space. Listening to breath sounds won't confirm a diagnosis.

a client comes to the ED in severe resp distress following left-sided blunt chest trauma. the norse notes absent breath sounds on the client's left side and a tracheal shift to the right. For which of the following procedures should the nurse prepare the client?

Chest tube insertion

A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student requires immediate intervention by the supervising nurse? a. Assessing the client's platelet count b. Choosing an 18-gauge, 2-inch needle c. Not aspirating prior to injection d. Swabbing the injection site with alcohol

Choosing an 18 gauge, 2 inch needle

A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.) a. Client who had a reaction to contrast dye yesterday b. Client with a new spinal cord injury on a rotating bed c. Middle-aged man with an exacerbation of asthma d. Older client who is 1-day post hip replacement surgery e. Young obese client with a fractured femur

Client with a new spinal cord injury on a rotating bed Older client who is 1-day post hip replacement surgery Young obese client with a fractured femur

A nurse is caring for a client following the insertion of a chest tube. The nurse should plan to have which of the following items in the client's room?

Container of sterile water

A nurse is assessing a client who has a chest tube in place following thoracic surgery. What finding indicates a need for intervention?

Continuous bubbling in the water seal chamber.

A nurse is assessing a patient who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the patient's pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate? A. Call the operating room to inform them of a pending emergency case. B. No action is needed at this time; this is a normal finding in some patients. C. Remove the tracheostomy tube; ventilate the patient with a bag-valve-mask. D. Stay with the patient and have someone else call the provider immediately.

D

A nurse is assessing a provider with the removal of a chest tube. Which of the following actions should the nurse take? a. instruct the client to lie prone with arms by the sides b. complete a surgical checklist on the client c. remind the client that there is minimal discomfort during the removal process d. place an occlusive dressing over the site once the tube is removed

D

A nurse is assessing the respiratory status of a male client who has suffered a fractured rib. The nurse would expect to note which of the following? a. Slow deep respirations b. Rapid deep respirations c. Paradoxical respirations d. Pain, especially with inspiration

D

A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. The most appropriate action by the nurse is to a. document the presence of a large air leak. b. obtain and attach a new collection device. c. notify the surgeon of a possible pneumothorax. d. take no further action with the collection device.

D

How should the nurse explain to the patient and family what the purpose of video-assisted thoracic surgery (VATS) is? a. removal of a lung b. removal of one or more lungs segments c. removal of lung tissue by multiple wedge sections d. inspection, diagnosis, and management of intrathoracic injuries

D

New bubbling is observed in the water seal chamber after a patient with a pleural chest tube returns from a test. The nurse clamps the chest tube momentarily with a tubing clamp at the dressing site. When this is done, bubbling in the water seal stops. The next appropriate nursing action is to: A. Continue to monitor the water seal chamber for bubbling every hour for the next four hours B. Do nothing. This bubbling is normal in patients with pleural chest tubes C. Call the physician immediately and do not leave the patient's bedside because of the risk of respiratory failure D. Remove the chest tube dressing to see if one or more eyelets of the chest tube have been pulled out of the chest

D

The HCP has inserted a chest tube in a client with a pneumothorax. The nurse should evaluate the effectiveness of the chest tube a. for administration of oxygen b. to promote formation of lung scar tissue c. to insert antibiotics into the pleural space d. to remove air and fluid

D

The nurse is caring for a client who was discharged 3 weeks ago after a diagnosis of pulmonary embolism (PE). He is currently admitted with gastrointestinal bleeding and an international normalized ratio (INR) of 6.9. For which of the following should the nurse assess this client? A. Consumption of green leafy vegetables B. Prolonged exhalation C. Client has massaged his calves. D. Use of aspirin or salicylates

D

The patient had video-assisted thoracic surgery (VATS) to perform a lobectomy. What does the nurse know is the reason for using this type of surgery? a. The patient has lung cancer. b. The incision will be medial sternal or lateral. c. Chest tubes will not be needed postoperatively. d. Less discomfort and faster return to normal activity

D

When assessing a 24-year-old patient who has just arrived after an automobile accident, the emergency department nurse notes that the breath sounds are absent on the right side. The nurse will anticipate the need for a. emergency pericardiocentesis. b. stabilization of the chest wall with tape. c. administration of an inhaled bronchodilator. d. insertion of a chest tube with a chest drainage system.

D

When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient? a.Emergency pericardiocentesis b.Stabilization of the chest wall with tape c.Administration of an inhaled bronchodilator d.Insertion of a chest tube with a chest drainage system

D

When caring for a client with a chest tube and water seal drainage system, the nurse should a. verify that the air vent on the water seal drainage system is capped when the suction is off b. strip the chest drainage tubes at least every 4 hours if excessive bleeding occurs c. ensure that the chest tube is clamped when moving the client out of the bed d. make sure that the drainage apparatus is always below the client's chest level

D

Which finding would suggest pneumothorax in a trauma victim? a. pronounced crackles b. inspiratory wheezing c. dullness on percussion d. absent breath sounds

D

Which intervention for a patient with a pulmonary embolus would the RN assign to the LPN/LVN on the patient care team? a. Evaluating the patient's reports of chest pain b. Monitoring laboratory values for changes in oxygenation c. Assessing for symptoms of respiratory failure d. Auscultating the lungs for crackles

D

Which of the following best describes pleural effusion? A. The collapse of alveoli B. The collapse of bronchiole C. The fluid in the alveolar space D. The accumulation of fluid between the linings of the pleural space

D

Which of the following diagnostic tools is the most accurate when confirming a diagnosis of PE? A) X-ray B) CT scan with contrast C) V/Q scan D) Pulmonary Angiogram

D

Which of the following statements is true about intrapleural (the space between the parietal and visceral or pulmonary pleurae) pressure under normal conditions? A. It is always positive B. It is negative during inhalation; positive during exhalation C. It is positive during inhalation; negative during exhalation D. It is always negative

D

Which of the following statements is true regarding patient movement while requiring chest drainage? (assume a physician order or protocol exists) A. Patients may go only from bed to a chair while the chest tube is connected to a chest drain B. If patient must leave nursing unit, suction tubing should be clamped shut while chest drain is disconnected from suction C. If a patient is ambulatory, the chest tube should be clamped shut while the chest drain is disconnected from suction D. Patients may walk around once the nurse disconnects the drain from suction as long as the drain remains below the chest

D

You are on the team taking care of the patient diagnosed with Pulmonary Embolism (PE). Which of the following activities takes priority? A) Immediate Intubation B) ABG/d-dimer C) Initiation of Heparin D) Insertion of IV lines

D

A client with shortness of breath has decreased to absent breath sounds on the right side, from the apex to the base. Which of the following conditions would best explain this?A. Acute asthma B. Chronic bronchitis C. Pneumonia D. Spontaneous pneumothorax

D. Spontaneous pneumothorax A spontaneous pneumothorax occurs when the client's lung collapses, causing an acute decrease in the amount of functional lung used in oxygenation. The sudden collapse was the cause of the chest pain & shortness of breath.

A client recovering from a pulmonary embolism after surgery is receiving low-molecular-weight heparin (Lovenox) and warfarin (Coumadin). The client's international normalized ratio (INR) is 2.4 today. After reporting this lab value to the provider, which order does the nurse anticipate? 1Continue the heparin and warfarin, and repeat the INR in one day. 2Discontinue the heparin and administer protamine sulfate. 3Discontinue the warfarin and administer phytonadione (AquaMEPHYTON) 4Discontinue the heparin and continue the warfarin.

Discontinue the heparin and continue the warfarin

A nurse is assessing a client following a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? Select all that apply a. tachypnea b. deviation of the trachea c. bradycardia d. decreased use of accessory muscles e. pleuritic pain

E

A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority? a. Apply oxygen at 100% .b. Assess the respiratory rate. c. Ensure a patent airway. d. Start two large-bore IV lines.

Ensure a patent airway

When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.) a. Avoid drinking alcohol. b. Eat more omega-3 fatty acids. c. Exercise on a regular basis. d. Maintain a healthy weight. e. Stop smoking cigarettes.

Exercise on a regular basis. Maintain a healthy weight. Stop smoking cigarettes.

A nurse is caring for a client on the medical stepdown unit. The following data are related to this client:Subjective InformationLaboratory AnalysisPhysical AssessmentShortness of breath for 20 minutesFeels frightened"Can't catch my breath"pH: 7.12PaCO2: 28 mm HgPaO2: 58 mm HgSaO2: 88%Pulse: 120 beats/minRespiratory rate: 34 breaths/minBlood pressure 158/92 mm HgLungs have cracklesWhat action by the nurse is most appropriate? a. Call respiratory therapy for a breathing treatment. b. Facilitate a STAT pulmonary angiography .c. Prepare for immediate endotracheal intubation. d. Prepare to administer intravenous anticoagulants.

Facilitate a STAT pulmonary angiography.

A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client's chest movement inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following? a. Atelectasis b. Flail chest c. Hemothorax d. Pneumothorax

Flail chest

The nurse is assisting in caring for a postoperative client who had a pneumonectomy. The nurse monitors the client for which adverse signs and symptoms indicating acute pulmonary edema? 1. Frothy sputum 2. Pain with deep breathing 3. Increased chest tube drainage 4. Respiratory rate of 20 breaths per minute

Frothy sputum

Which symptoms in a client assist the nurse in confirming the diagnosis of pulmonary embolus (PE)? (Select all that apply.)

Hemoptysis Sharp chest pain Hypotension

A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering? a. Furosemide b. Dexamethasone c. Heparin d. Atropine

Heparin

The nurse is developing a plan of care for a client with pulmonary embolism (PE). Which client problem does the nurse establish as the priority? 1Inadequate nutrition related to food-drug interactions and anticoagulant therapy 2Potential for infection related to leukocytosis 3Hypoxemia related to ventilation-perfusion mismatch 4Insufficient knowledge related to the cause of PE

Hypoxemia related to ventilation-perfusion mismatch

A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate? a. Decrease the heparin rate. b. Increase the heparin rate. c. No change to the heparin rate. d. Stop heparin; start warfarin (Coumadin).

Increase heparin rate

A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication? a. Hamburger and French fries b. Large chef's salad and muffin c. No selection; spouse brings pizza d. Tuna salad sandwich and chips

Large chefs salad and muffin

A nurse is assessing a client who has pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

Movement of the trachea toward the unaffected side

The nurse is assisting in planning care for a client scheduled for insertion of a tracheostomy. Which equipment should the nurse plan to have at the bedside when the client returns from surgery? 1. Obturator 2. Oral airway 3. Epinephrine 4. Tracheostomy tube with the next larger size

Obturator

A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred? a. Hemoglobin: 14.2 g/dL b. Platelet count: 82,000/L c. Red blood cell count: 4.8/mm3 d. White blood cell count: 8.7/mm3

Platelet count: 82,000/L

A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals the client has an alteration in the gene CYP2C19. What action by the nurse is best? a. Instruct the client to eliminate all vitamin K from the diet. b. Prepare preoperative teaching for an inferior vena cava (IVC) filter. c. Refer the client to a chronic illness support group. d. Teach the client to use a soft-bristled toothbrush.

Prepare preoperative teaching for an inferior vena cava (IVC) filter.

A client is brought to the emergency department after sustaining injuries in a severe car crash. The client's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action by the nurse is the priority?

Prepare to assist with intubation

A client is receiving heparin sodium (Hepalean) therapy for a pulmonary embolism. Which antidote does the nurse confirm is available on the unit? 1Vitamin K 2Protamine sulfate 3Antihemophilic factor 4Aminocaproic acid

Protamine Sulfate

The nurse assesses a client who has a hemothorax and a chest tube inserted on the right side. What finding requires immediate attention?

Puffiness of the skin around the chest tube insertion site and a crackling feeling

A client recovering from an osteotomy and pin fixation for a femur fracture suddenly experiences shortness of breath, chest pain, and tachycardia. What does the nurse suspect is causing the client's symptoms? 1Pulmonary infection 2Reaction to anesthesia 3Pulmonary embolism 4Pulmonary edema

Pulmonary Embolism

A nurse is monitoring a client who has a chest tube in place connected to wall due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take?

Reposition the patient

A nurse in a critical care unit is caring for a client who is postoperative following a right pneumonectomy. After extubation from the ventilator, in which of the following positions should the client be placed?

Semi-fowlers

The nurse is suctioning an adult client through a tracheostomy tube. During the procedure, the nurse notes that the client's oxygen saturation by pulse oximetry is 89%. Which action should the nurse implement? 1. Continue suctioning. 2. Call respiratory therapy. 3. Stop the suctioning procedure. 4. Obtain a smaller suction catheter.

Stop the suctioning procedure

A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management? a. Poor visual acuity b. Strict vegetarian c. Refusal to stop smoking d. Wants weight loss surgery

Strict vegitarian

A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate? a. Encourage the client to walk 5 minutes each hour. b. Refer the client to smoking cessation classes. c. Teach the client about factor V Leiden testing. d. Tell the client that sometimes no cause for disease is found.

Teach the client about factor V Leiden testing.

A nurse working in the emergency department is caring for a client following a chest trauma. What findings indicates a tension pneumothorax?

Tracheal deviation to the unaffected side.

A client with a tracheostomy gets easily frustrated when trying to communicate personal needs to the nurse. The nurse determines that which method for communication may be the easiest for the client? 1. Use a pad and paper. 2. Use a picture or word board. 3. Have the family interpret needs. 4. Devise a system of hand signals.

Use a picture or word board

The nurse is caring for a client with a high risk for pulmonary embolism (PE). Which prevention measures does the nurse add to the client's care plan? (Select all that apply.)

Use antiembolism stockings.Turn every 2 hours if client is in bed.

The best method for determining the risk of aspiration in a patient with a tracheostomy is to a. consult a speech therapist for swallowing assessment. b. have the patient drink plain water and assess for coughing c. assess for change of sputum color 48 hours after patient drinks small amount of blue dye. d. suction above the cuff after the patients eats or drinks to determine presence of food in trachea.

a Rationale: The ability to swallow secretions without aspiration has traditionally been evaluated with the use of blue dye. A teaspoon of water colored with blue dye is swallowed by the patient. Respiratory secretions are then monitored for 24 hours for appearance of the dye, which would indicate aspiration. Recent studies, however, do not support the sensitivity of this test. It is therefore no longer recommended. Instead, clinical assessment by a speech therapist, videofluoroscopy, or fiberoptic endoscopic evaluations of swallow are recommended. Patients should begin swallowing with thickened liquids, not plain water. Ability to swallow should be assessed with the cuff deflated, inasmuch as cuff inflation may interfere with swallowing ability.

A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration? a. Continue to monitor the client b. Immediately notify the provider c. Reposition the client toward the left side d. Clamp the chest tube near the water seal

a. Continue to monitor the client

A nurse is caring for a client who has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication? a. Continuous bubbling in the water-seal chamber b. Occasional bubbling in the water-seal chamber c. Constant bubbling in the suction-control chamber d. Fluctuations in the fluid level in the water-seal chamber

a. Continuous bubbling in the water-seal chamber

Nurse Kim is caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is appropriate? a. Do nothing, because this is an expected finding. b. Immediately clamp the chest tube and notify the physician. c. Check for an air leak because the bubbling should be intermittent. d. Increase the suction pressure so that bubbling becomes vigorous.

a. Do nothing, because this is an expected finding.

The nurse in trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first? a. Evaluate chest expansion b. Check pupillary response to light c. Assess the capillary refill d. Check client's response to questions about place and time

a. Evaluate chest expansion

The nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly? a. Fluctuation of the fluid level within the water seal chamber b. Absence of fluid in the drainage tubing c. Continuous bubbling within the water seal chamber d. Equal amounts of fluid drainage in each collection chamber

a. Fluctuation of the fluid level within the water seal chamber

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first? a. Give morphine IV b. Administer oxygen therapy c. Start an IV infusion of lactated Ringer's d. Initiate cardiac monitoring

b. Administer oxygen therapy

A nurse is caring for a client who is 12hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations? a. Constant bubbling in the suction-control chamber b. Continuous bubbling in the water-seal chamber c. Bloody drainage in the collection chamber d. Fluid-level fluctuations in the water-seal chamber

b. Continuous bubbling in the water-seal chamber

A nurse is caring for a client who has a newly inserted chest drainage system with a water seal. Which of the following actions should the nurse take? a. Clamp the tube with the client is ambulating b. Keep the collection device below the level of the client's chest c. Coil the tubes carefully to prevent kinking d. Lay the client flat to avoid leaks in the tubing

b. Keep the collection device below the level of the client's chest

A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded? a. Oxygen saturation of 95% b. No fluctuations in the water seal chamber c. No reports of pleuritic chest pain d. Occasional bubbling in the water-seal chamber

b. No fluctuations in the water seal chamber

A nurse is caring for a client who has a 3-chamber closed chest tube. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration?

continue to monitor the client

A client has severe pain from three rib fractures after a workplace accident. To facilitate adequate respiration, the nurse discusses which intervention with the provider? 1Administering opioid analgesics 2Intercostal nerve block 3Mechanical ventilation 4Splinting the ribs with tape

intercostal nerve block

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the xray department. which of the following actions should the nurse take?

keep the drainage system below the level of the clients chest at all times.