Acute Care Exam 1 Practice
Benefits of CPAP
-Continuous pressure -used for weaning -reduce patient anxiety -maintains lung volume & keeps airway open
Care for a client w/post-embolectomy after a pulmonary embolism. What do you assess + do to care for that patient?
A surgical embolectomy is rarely performed but may be indicated if there are c/i to thrombolytic therapy. Embolectomy can be performed using catheters or surgically. Surgical removal must be performed by a cardiovascular surgical team w/the patient on cardiopulmonary bypass. If the patient has undergone surgical embolectomy, the nurse measures the patient's pulmonary arterial pressure + urinary output. The nurse also assesses the insertion site of the arterial catheter for hematoma formation + infection. Maintaining the blood pressure at a level that supports perfusion of vital organs is crucial. To prevent peripheral venous stasis + edema of the lower extremities, the nurse elevates the foot of the bed + encourages isometric exercises, the use of intermittent pneumatic compression devices, + walking when the patient is permitted out of bed. Sitting for long periods is discouraged, b/c hip flexion compresses the large veins in the legs.
A cardiac patient's resistance to left ventricular filling has caused blood to back up into the patient's circulatory system. What health problem is likely to result? A) Acute pulmonary edema B) Right-sided HF C) Right ventricular hypertrophy D) Left-sided HF
A) Acute pulmonary edema
A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, + postural drainage. Prior to the procedure, which of the following nursing actions should the nurse complete first? A) Auscultate lung fields B) Assess pulse + respirations C) Assess characteristics of her sputum Instruct to slowly exhale w/pursed lips
A) Auscultate lung fields
The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis of lung cancer. While assisting w/a subclavian vein central line insertion, the nurse notes the client's oxygen saturation rapidly dropping. The patient complains of SOB + becomes tachypneic. The nurse suspects a pneumothorax hsa developed. Further assessment findings supporting the presence of a pneumothorax include what? A) Diminished or absent breath sounds on the affected side B) Paradoxical chest wall movement w/respirations C) Sudden loss of consciousness D) muffled heart sounds
A) Diminished or absent breath sounds on the affected side
A nurse is caring or a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? SATA A) Dyspnea B) Bradycardia C) Barrel chest D) Clubbing of the fingers E) Deep Respirations
A) Dyspnea C) Barrel chest D) Clubbing of the fingers
A patient has just been admitted to the ED + requires high-flow oxygen therapy after suffering facial burns + smoke inhalation. Which oxygen delivery device should the nurse use initially? A) Face tent B) Venturi mask C) Nasal cannula Non-rebreather
A) Face tent
In a client w/a tracheostomy, the nurse should monitor for complications related to the loss of which protective mechanism? A) Filtration + humidification of inspired air B) The ability to cough C) Decrease in oxygen-carrying capacity of the trachea The sneeze reflex initiated by irritant in the nasal passages
A) Filtration + humidification of inspired air
The nurse is caring for a postoperative client who has a chest tube connected to suction + 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 w/in the water seal chamber B) Absence of fluid in the drainage tubing C) Continuous bubbling w/in the water seal chamber D) Equal amounts of fluid drainage in each collection chamber
A) Fluctuation of the fluid level w/in the water seal chamber
A patient has been exposed to a nerve agent in a biochemical terrorist attack. This type of agent bonds w/acetylcholinesterase, so that acetylcholine is not inactivated. What is the pathologic effect of this type of agent? A) Hyperstimulation of the nerve endings B) Temporary deactivation of the nerve endings C) Binding of the nerve endings D) Destruction of the nerve endings
A) Hyperstimulation of the nerve endings
A backcountry skier has been airlifted to the ED after becoming lost + developing hypothermia + frostbite. How should the nurse best manage the patient's frostbite? A) Immerse affected extremities in water slightly above normal body temperature. B) Immerse the patient's frostbitten extremities in the warmest water the patient can tolerate. C) Gently massage the patient's frozen extremities in between water baths. Perform passive ROM exercises of the affected extremities to promote circulation.
A) Immerse affected extremities in water slightly above normal body temperature.
The nurse is caring for a patient w/a lower respiratory tract infection. When planning a focused respiratory assessment, the nurse should know that this type of infection most often causes what? A) Impaired gas exchange B) Collapsed bronchial structures C) Necrosis of the alveoli D) Closed bronchial tree
A) Impaired gas exchange
A patient admitted to the medical unit w/HF is exhibiting s/s of pulmonary edema. The nurse is aware that positioning will promote circulation. How should the nurse best position the patient? A) In a high Fowler's position B) On the left side-lying position C) In a flat, supine position D) In the Trendelenburg position
A) In a high Fowler's position
The nurse is caring for a patient at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the patient. What is an example of a first-line measure to minimize atelectasis? A) Incentive spirometry B) Intermittent positive-pressure breathing (IPPB) C) Positive end-expiratory pressure (PEEP) D) Bronchoscopy
A) Incentive spirometry
A client w/ARDS has fine crackles at lung bases, + the respirations are shallow at a rate of 28 breaths/min. The client is restless + anxious. In addition to monitoring the arterial blood gas results, what should the nurse do? SATA A) Monitor serum creatinine + BUN levels B) Administer a sedative C) Keep the HOB flat D) Administer humidified oxygen E) Auscultate the lungs
A) Monitor serum creatinine + BUN levels D) Administer humidified oxygen E) Auscultate the lungs
A nurse is assessing a client who has a pneumothorax w/a chest tube in place. For which of the following findings should the nurse notify the provider? A) Movement of the trachea toward the unaffected side B) Bubbling of the water in the water seal chamber w/exhalation C) Crepitus in the area above + surrounding the insertion site D) Eyelets are not visible
A) Movement of the trachea toward the unaffected side
A patient is being treated in the ED following a terrorist attack. The patient is experiencing visual disturbances, nausea, vomiting + behavioral changes. The nurse suspects this patient has been exposed to what chemical change? A) Nerve agent B) Pulmonary agent C) Vesicant D) Blood agent
A) Nerve agent
A patient on the medical unit has told the nurse that he is experiencing significant dyspnea, despite that he has not recently performed any physical activity. What assessment questions should the nurse ask the patient while preparing to perform a physical assessment? A) On a scale from 1 to 10, how bad would you rate your SOB? B) When was the last time you ate or drank anything? C) Are you feeling any nausea along w/your SOB? D) Do you think that some medication might help you catch your breath?
A) On a scale from 1 to 10, how bad would you rate your SOB?
A critical care nurse is aware of the high incidence of ventilator-associated pneumonia (VAP) in patients who are being treated for shock. What intervention should be specified in the patient's POC while the patient is ventilated? A) Performing frequent oral care B) Maintaining the patient in a supine position C) Suctioning the patient every 15 minutes unless c/i D) Administering prophylactic abx, as ordered
A) Performing frequent oral care
The nurse is assessing an adult patient following a motor vehicle accident. The nurse observes that the patient has an increased use of accessory muscles + is complaining of chest pain + SOB. The nurse should recognize the possibility of what condition? A) Pneumothorax B) Anxiety C) Acute bronchitis D) Aspiration
A) Pneumothorax
A patient has been brought to the ED by the paramedics. The patient is suspected of having ARDS. What intervention should the nurse first anticipate? A) Preparing to assist with intubating the patient B) Setting up oxygen at 5 L/minute by nasal cannula C) Performing deep suctioning D) Setting up a nebulizer to administer corticosteroids
A) Preparing to assist with intubating the patient
The nurse is caring for a patient who has returned to the unit following a bronchoscopy. The patient is asking for something to drink. Which criterion will determine when the nurse should allow the patient to drink fluids? A) Presence of a cough + gag reflex B) Absence of nausea C) Ability to demonstrate deep inspiration D) Oxygen saturation of 92%
A) Presence of a cough + gag reflex
A cardiovascular patient w/a previous hx of PE is experiencing a sudden onset of dyspnea, rapid breathing, + chest pain. The nurse recognizes the characteristic s/s of a PE. What is the nurse's best action? A) Rapidly assess the patient's cardiopulmonary status. B) Arrange for an ECG. C) Increase the height of the patient's bed. D) Manage the patient's anxiety.
A) Rapidly assess the patient's cardiopulmonary status.
Which finding should prompt urgent re-evaluation of a patient w/a chest tube? A) SOB B) Malar rash C) Constipation D) Diarrhea E) Arthritis F) Dry mouth
A) SOB
A patient w/emphysema is experiencing SOB. To relieve this patient's symptoms, the nurse should assist her into what position? A) Sitting upright, leaning forward slightly B) Low Fowler's, w/the neck slightly hyperextended C) Prone D) Trendelenburg
A) Sitting upright, leaning forward slightly
A patient is receiving a blood transfusion + complains of a new onset of slight dyspnea. The nurse's rapid assessment reveals bilateral lung crackles + elevated BP. What is the nurse's most appropriate action? A) Slow the infusion rate + monitor the patient closely. B) Discontinue the transfusion + begin resuscitation. C) Pause the transfusion + administer a 250 mL bolus of normal saline. D) Discontinue the transfusion + administer a beta-blocker, as ordered.
A) Slow the infusion rate + monitor the patient closely.
A nurse takes a shift report + finds he is caring for a patient who has been exposed to anthrax by inhalation. What precautions does the nurse know must be put in place when providing care for this patient? A) Standard precautions B) Airborne precautions C) Droplet precautions D) Contact precautions
A) Standard precautions
An x-ray of a trauma patient reveals rib fractures + the patient is dx w/a small flail chest injury. Which intervention should the nurse include in the patient's POC? A) Suction the patient's airway secretions. B) Immobilize the ribs w/an abdominal binder. C) Prepare the patient for surgery. D) Immediately sedate + intubate the patient.
A) Suction the patient's airway secretions.
A nurse is performing tracheostomy care for a client + suctioning to remove copious secretions. Which of the following actions should the nurse take? A) Suction two to three times w/a 60 second pause between passes B) Perform chest physiotherapy prior to suctioning C) Lubricate the suction catheter tip w/sterile saline Hyperventilate the client on 100% oxygen prior to suctioning
A) Suction two to three times w/a 60 second pause between passes
A nurse is admitting a new patient who has been admitted w/a dx of COPD exacerbation. How can the nurse best help the patient achieve the goal of maintaining effective oxygenation? A) Teach the patient strategies for promoting diaphragmatic breathing. B) Administer supplementary oxygen by simple face mask. C) Teach the patient to perform airway suctioning. D) Assist the patient in developing an appropriate exercise program.
A) Teach the patient strategies for promoting diaphragmatic breathing.
The ED nurse is assessing a patient complaining of dyspnea. The nurse auscultates the patient's chest + hears wheezes throughout the lung fields. What might this indicate? A) The patient has a narrowed airway. B) The patient has pneumonia C) The patient needs physiotherapy D) The patient has a hemothorax
A) The patient has a narrowed airway.
A patient w/mitral valve prolapse is admitted for a scheduled bronchoscopy to investigate recent hemoptysis. The physician has ordered gentamicin to be taken before the procedure. What is the rationale for this? A) To prevent bacterial endocarditis B) To prevent hospital-acquired pneumonia C) To minimize the need for antibiotic use during the procedure D) To decrease the need for surgical asepsis
A) To prevent bacterial endocarditis
The nurse is developing a POC for a patient w/Guillain-Barre syndrome. Which of the following interventions should the nurse prioritize for this patient? A) Using the incentive spirometer as prescribed B) Maintaining the patient on bed rest C) Providing aids to compensate for loss of vision D) Assessing frequently for loss of cognitive function
A) Using the incentive spirometer as prescribed
During auscultation, what is most often heard in a patient w/pneumonia? A) Wheezing or crackles B) Stridor C) Bronchial breath sounds D) Grunting E) Crepitus Rhonchi
A) Wheezing or crackles
A nurse is caring for a client who just had a flexible bronchoscopy. Which of the following nursing actions is appropriate? A) Withhold food + liquids until the client's gag reflex returns. B) Irrigate the client's throat every 4 hr. C) Have the client refrain from talking for 24 hr. D) Suction the client's oropharynx frequently.
A) Withhold food + liquids until the client's gag reflex returns.
Which independent nursing interventions are appropriate for a client who is experiencing an alteration in oxygenation? SATA A) encouraging deep breathing exercises B) assisting w/positioning C) providing suctioning D) prescribing bronchodilators E) monitoring activity tolerance
A) encouraging deep breathing exercises B) assisting w/positioning C) providing suctioning E) monitoring activity tolerance
What is the first step in management after receiving a patient w/a chest tube? A) Increase suction B) Confirm suction order C) Slowly change position D) Change to simple masks E) Change to venturi masks F) Confirm body alignment
B) Confirm suction order
A patient w/thoracic trauma is admitted to the ICU. The nurse notes the patient's chest + neck are swollen + there is a crackling sensation when palpated. The nurse consequently identifies the presence of subcutaneous emphysema. If this condition becomes severe + threatens airway patency, what intervention is indicated? A) a chest tube B) A tracheostomy C) An endotracheal tube D) A feeding tube
B) A tracheostomy
A patient presents to the Ed complaining of increasing SOB. The nurse assessing the patient notes a hx of left-sided HF. The patient is agitated + occasionally coughing up pink-tinged, foamy sputum. The nurse should recognize the s/s of what health problem? A) Right-sided HF B) Acute pulmonary edema C) Pneumonia D) Cardiogenic shock
B) Acute pulmonary edema
A nurse is caring for a client who is 12 hr postoperative + has a chest tube to a disposable water-seal drainage system w/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
Regarding chest tube management + care, what is the physical exam finding associated w/subcutaneous emphysema? A) Dyspnea + respiratory distress B) Crepitus C) Respiratory depression D) Hematemesis E) Coughing Hyperventilation
B) Crepitus
A critical care nurse is planning assessments in the knowledge that patients in shock are vulnerable to developing fluid replacement complications. For what signs + symptoms should the nurse monitor the patient? SATA A) Hypovolemia B) Difficulty breathing C) Cardiovascular overload D) Pulmonary edema E) Hypoglycemia
B) Difficulty breathing C) Cardiovascular overload D) Pulmonary edema
The nurse doing rounds at the beginning of a shift notices a sputum specimen in a container sitting on the bedside table in a patient's room. The nurse asks the patient when he produced the sputum specimen + he states that the specimen is about 4 hours old. What action should the nurse take? A) Immediately take the sputum specimen to the laboratory. B) Discard the specimen + assist the patient in obtaining another specimen. C) Refrigerate the sputum specimen + submit it once it is chilled. D) Add a small amount of normal saline to moisten the specimen.
B) Discard the specimen + assist the patient in obtaining another specimen.
During your assessment of a patient w/suspected ARDS, which of the following findings is most likely to be seen? A) Diarrhea B) Dyspnea C) Jaw claudication D) Pulmonary hypotension E) Bradypnea F) Obstructive sleep apnea (OSA)
B) Dyspnea
An admitting nurse is assessing a patient w/COPD. The nurse auscultates diminished breath sounds, which signify changes in the airway. These changes indicate to the nurse to monitor the patient for what? A) Kyphosis + clubbing of the fingers B) Dyspnea + hypoxemia C) Sepsis + pneumothorax D) Bradypnea + pursed lip breathing
B) Dyspnea + hypoxemia
A 6 yr old is admitted to the ED after being rescued from a pond after falling through the ice while ice skating. What action should the nurse perform while rewarming the patient? A) Assessing the patient's oral temperature frequently B) Ensuring continuous ECG monitoring C) Massaging the patient's skin surfaces to promote circulation D) Administering bronchodilators by nebulizer
B) Ensuring continuous ECG monitoring
Regarding chest tubes, which finding in the suction system indicates a significant air leak? A) Minimal bubbling B) Excessive bubbling C) No bubbling D) Chest pain E) Hypoxemia F) SOB
B) Excessive bubbling
A sputum study has been ordered for a patient who has developed coarse chest crackles + a fever. At what time should the nurse best collect the sample? A) Immediately after a meal B) First thing in the morning C) At bedtime D) After a period of exercise
B) First thing in the morning
Which statement is most accurate regarding chest tubes? A) If the drainage system is damaged, occlude drainage tube w/surgical tape B) If the drainage system is damaged, place disconnected drainage tube in sterile water C) If the drainage system is damaged, twist drainage tube to prevent fluid loss D) If the drainage system is damaged, place disconnected drainage tube in loosely wrapped gauze E) If the drainage system is damaged, place disconnected drainage tube in isopropyl alcohol F) If the drainage system is damaged, patch any leaks in the tubing w/surgical tape
B) If the drainage system is damaged, place disconnected drainage tube in sterile water
The nurse is caring for a patient w/lung metastases who just underwent a mediastinotomy. What should be the focus of the nurse's postprocedure care? A) Assisting w/pulmonary function testing (PFT) B) Maintaining the patient's chest tube C) Administering oral suction as needed D) Performing chest physiotherapy
B) Maintaining the patient's chest tube
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 firefighter was trapped in a fire + is admitted to the ICU for smoke inhalation. After 12 hours, the firefighter is exhibiting signs of ARDS + is not intubated. What other supportive measures are initiated in a patient w/ARDS? A) Psychological counseling B) Nutritional support C) High-protein oral diet D) Occupational therapy
B) Nutritional support
A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), + requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes? A) Decrease chest wall compliance B) Suppress respiratory effort C) Induce sedation D) Decrease respiratory secretions
B) Suppress respiratory effort
A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), + requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes? A) Decrease chest wall compliance B) Suppress respiratory effort C) Induce sedation D) Decrease respiratory secretions
B) Suppress respiratory effort
The nurse is providing preoperative teaching to a patient scheduled for surgery. The nurse is instructing the patient on the use of deep breathing, coughing, + use of incentive spirometry when the patient states, "I don't know why you're focusing on my breathing. My surgery is on my hip, not my chest." What rationale for these instructions should the nurse provide? A) To prevent COPD B) To promote optimal lung expansion C) To enhance peripheral circulation D) To prevent pneumothorax
B) To promote optimal lung expansion
A patient w/an acute exacerbation of chronic obstructive pulmonary disease (COPD) needs to receive precise amounts of oxygen. Which equipment should the nurse prepare to use? A) Oxygen tent B) Venturi mask C) Nasal cannula D) Oxygen-conserving cannula
B) Venturi mask
The nurse is preparing to assess an older adult client admitted w/TB. Which assessment finding does the nurse anticipate? A) Night sweats B) Swollen lymph nodes C) Cough D) Hemoptysis
C) Cough
What is a bronchoscopy? What is it for?
Bronchoscopy is the direct inspection + examination of the larynx, trachea, + bronchi through either a flexible fiberoptic bronchoscope or a rigid bronchoscope. The fiberoptic scope is used more frequently in current practice. The purposes of diagnostic bronchoscopy are (1) to visualize tissues + determine the nature, location, + extent of the pathologic process; (2) to collect secretions for analysis + to obtain a tissue sample for diagnosis; (3) to determine whether a tumor can be resected surgically; + (4) to diagnose sources of hemoptysis Therapeutic bronchoscopy is used to (1) remove foreign bodies or secretions from the tracheobronchial tree, (2) control bleeding, (3) treat postoperative atelectasis, (4) destroy + excise lesions, + (5) provide brachytherapy (endobronchial radiation therapy). Also used for stent insertion to relieve airway obstruction that is caused by tumors or miscellaneous benign conditions or that occurs as a complication of lung transplantation. The fiber optic bronchoscope is a thin, flexible bronchoscope that can be directed into the segmental bronchi. Because of its small size, its flexibility, + its excellent optical system, it allows increased visualization of the peripheral airways + is ideal for diagnosing pulmonary lesions. Fiber optic bronchoscopy allows biopsy of previously inaccessible tumors + can be performed at the bedside. It also can be performed through ET or tracheostomy tubes of patients on ventilators. Cytologic examinations can be performed w/out surgical intervention. The rigid bronchoscope is a hollow metal tube w/a light at its end. It is used mainly for removing foreign substances, investigating the source of massive hemoptysis, or performing endobronchial surgical procedures. Rigid bronchoscopy is performed in the operating room, not at the bedside. Possible complications = possible reaction to the local anesthetic, oversedation, prolonged fever, infection, aspiration, vasovagal response, laryngospasm, bronchospasm, hypoxemia, pneumothorax, + bleeding.
A patient has been admitted to the medical unit w/s/s that are suggestive of anthrax infection. The nurse should anticipate what intervention? A) Administration of acyclovir B) Hematopoietic stem cell transplantation (HSCT) C) Administration of penicillin D) Hemodialysis
C) Administration of penicillin
The ED nurse is assessing the respiratory function of a teenage girl who presented w/acute SOB. Auscultation reveals continuous wheezes during inspiration + expiration. This finding is most suggestive of what? A) Pleurisy B) Emphysema C) Asthma D) Pneumonia
C) Asthma
A nurse is providing teaching to a client who has emphysema + a new prescription for theophylline. Which of the following instructions should the nurse provide? A) Consume a high-protein diet. B) Administer the medication w/food. C) Avoid caffeine while taking this medication. D) Increase fluid to 1 L/day.
C) Avoid caffeine while taking this medication.
The nurse is caring for an 84 yr old man who has just returned from the OR after inguinal hernia repair. The OR report indicates that the patient received large volumes of IV fluid during surgery + the nurse recognizes that the patient is at risk for left-sided HF. What s/s would indicate left-sided HF? A) Jugular vein distention B) Right upper quadrant pain C) Bibasilar fine crackles D) Dependent edema
C) Bibasilar fine crackles
The nurse assesses a patient w/tachypnea + clubbing of the fingers. Based on this data, which dx does the nurse anticipate for this patient? A) Asthma B) Chest trauma C) Chronic hypoxemia D) Chronic pulmonary obstructive disease
C) Chronic hypoxemia
The nurse is caring for an elderly patient in the PACU. The patient has had a bronchoscopy, + the nurse is monitoring for complications related to the administration of lidocaine. For what complication related to the administration of large doses of lidocaine in the elderly should the nurse assess? A) Decreased urine output + HTN B) HA + vision changes C) Confusion + lethargy D) Jaundice + elevated liver enzymes
C) Confusion + lethargy
A nurse is developing a POC for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications? A) Perform ROM exercises B) Place suction equipment at the bedside C) Encourage the use of an incentive spirometer D) Administer an expectorant
C) Encourage the use of an incentive spirometer
You are caring for a 71 yr old patient who is 4 days postoperative for bilateral inguinal hernias. The patient has a hx of congestive HF + PUD. The patient is highly reluctant to ambulate + will not drink fluids except for hot tea w/her meals. The nurse's aide reports to you that this patient's VS are slightly elevated + that she has a nonproductive cough. When you assess the patient, you auscultate crackles at the base of the lungs. What would you suspect is wrong w/your patient? A) Pulmonary embolism B) Hypervolemia C) Hypostatic pulmonary congestion D) Malignant hyperthermia
C) Hypostatic pulmonary congestion
The nurse is caring for a patient in the ICU admitted w/ARDS after exposure to toxic fumes from a hazardous spill at work. The patient has become hypotensive. What is the cause of this complication to the ARDS treatment? A) Pulmonary hypotension due to decreased cardiac output. B) Severe + progressive pulmonary HTN C) Hypovolemia secondary to leakage of fluid into the interstitial spaces D) Increased cardiac output from high levels of PEEP therapy
C) Hypovolemia secondary to leakage of fluid into the interstitial spaces
Which statement is most accurate regarding chest tubes? A) If tube dislodges from patient, clean w/sterile water. B) If tube dislodges from patient, use regular gauze taped 3 ways C) If tube dislodges from patient, use petroleum gauze taped 3 ways D) If tube dislodges from patient use zinc oxide + gauze taped 3 ways E) If tube dislodges from patient, clean w/alcohol solution F) If tube dislodges from patient, use surgical tape over site
C) If tube dislodges from patient, use petroleum gauze taped 3 ways
A nurse is monitoring a client following thoracentesis. The nurse should identify which of the following manifestations as a complication + contact the provider immediately? A) Serosanguineous drainage from the puncture site B) Discomfort at the puncture site C) Increased heart rate D) Decreased temperature
C) Increased heart rate
A medical nurse has admitted a patient to the unit w/a dx of failure to thrive. The patient has developed a fever + cough, so a sputum specimen has been obtained. The nurse notes that the sputum is greenish + that there is a large quantity of it. The nurse notifies the patient's physician b/c these symptoms are suggestive of what? A) Pneumothorax B) Lung tumors C) Infection D) Pulmonary edema
C) Infection
A nurse is caring for a client who has a chest tube connected to a closed drainage system + needs to be transported to the x-ray department. Which of the following actions should the nurse take? A) Clamp the chest tube prior to transferring the client to a wheelchair. B) Disconnect the chest tube from the drainage system during transport. C) Keep the drainage system below the level of the client's chest at all times. D) Empty the collection chamber prior to transport.
C) Keep the drainage system below the level of the client's chest at all times.
Regarding chest tube management, when there is no oscillation in the water chamber, what should you check the suction system for? A) Excessive suction B) Impaired oxygenation C) Kinking D) Inadequate suction E) Contamination F) Air leak
C) Kinking
A patient is undergoing testing to see if he has a pleural effusion. Which of the nurse's respiratory assessment findings would be most consistent w/this diagnosis? A) Increased tactile fremitus, egophony, + a dull sound upon percussion of the chest wall B) Decreased tactile fremitus, wheezing, + a hyperresonant sound upon percussion of the chest wall C) Lung fields dull to percussion, absent breath sounds, + a pleural friction rub D) Normal tactile fremitus, decreased breath sounds, + a resonant sound upon percussion of the chest wall
C) Lung fields dull to percussion, absent breath sounds, + a pleural friction rub
Which action should the nurse anticipate in a client who has been diagnosed w/ARDS? A) Tracheostomy B) Use of a nasal cannula C) Mechanical ventilation D) Insertion of a chest tube
C) Mechanical ventilation
A nurse is caring for a client w/a tracheostomy. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's d/c? A) Attending a class given about tracheostomy care B) Verbalizing all steps in the procedure C) Performing the procedure independently D) Asking appropriate questions about suctioning
C) Performing the procedure independently
A patient arrives in the ED w/an attack of acute bronchiectasis. Chest auscultation reveals the presence of copious secretions. What intervention should the nurse prioritize in this patient's care? A) Oral administration of diuretics B) Intravenous fluids to reduce the viscosity of secretions C) Postural chest drainage D) Pulmonary function testing
C) Postural chest drainage
The nurse notes that a patient has developed a cough productive for mucoid sputum, is SOB, has cyanotic hands, + has noisy, moist-sounding, rapid breathing. These symptoms + signs are suggestive of what health problem? A) Pericarditis B) Cardiomyopathy C) Pulmonary edema D) Right ventricular hypertrophy
C) Pulmonary edema
The nurse is caring for a patient who has developed obvious signs of pulmonary edema. What is the priority nursing action? A) Lay the patient flat. B) Notify the family of the patient's critical state. C) Stay w/the patient. D) Update the physician
C) Stay w/the patient.
The nurse has placed the intubated client w/Acute Respiratory Distress Syndrome (ARDS) in a prone position for 30 minutes. Which factors would require the nurse to discontinue prone positioning + return the client to the supine position? SATA A) The family is coming to visit. B) The client has increased secretions requiring frequent suctioning. C) The SpO2 + PO2 have decreased. D) The client is tachycardic w/drop in BP. E) The face hsa increased skin breakdown + edema.
C) The SpO2 + PO2 have decreased. D) The client is tachycardic w/drop in BP. E) The face hsa increased skin breakdown + edema.
A nurse is caring for a group of clients in an infectious disease unit. The nurse should wear an OSHA-approved N95 respirator mask when caring for a client w/which of the following infectious diseases? A) Pertussis B) Mycoplasma pneumonia C) Tuberculosis D) Respiratory syncytial virus
C) Tuberculosis
A nurse is caring for a critically ill patient w/COPD who requires delivery of a precise concentration of oxygen. Which of the following types of oxygen-delivery device is indicated for this patient? A) Simple face mask B) Nasal cannula C) Venturi mask D) Face tent
C) Venturi mask
A nurse is caring for a client who is 1 day postoperative following a left lower lobectomy + has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? A) Continue to monitor the client as this is an expected finding B) Add more water to the suction control chamber of the drainage system C) Verify that the suction regulator is on + check the tubing for leaks D) Milk the chest tube + dislodge any clots in the tubing that are occluding it
C) Verify that the suction regulator is on + check the tubing for leaks
A nurse is teaching a client who will undergo a bronchoscopy procedure. The provider will use a rigid scope + general anesthesia. The nurse should explain that the client's neck will be in which of the following positions? A) A flexed position B) An extended position C) A neutral position D) A hyperextended position
D) A hyperextended position
A 66-yr old patient is in a hospice receiving palliative care for lung cancer which has metastasized to the patient's liver + bones. For the past several hours, the patient has been experiencing dyspnea. What nursing action is most appropriate to help to relieve the dyspnea the patient is experiencing? A) Administer a bolus of NS, as ordered. B) Initiate high-flow oxygen therapy. C) Administer high doses of opioids. D) Administer bronchodilators + corticosteroids, as ordered.
D) Administer bronchodilators + corticosteroids, as ordered.
A patient who has been exposed to anthrax is being treated in the local hospital. The nurse should prioritize what health assessments? A) Integumentary assessment B) Assessment for signs of hemorrhage C) Neurologic assessment D) Assessment of respiratory status
D) Assessment of respiratory status
A patient is admitted to the ED who has been exposed to a nerve agent. The nurse should anticipate the STAT administration of what drug? A) Amyl nitrate B) Dimercaprol C) Erythromycin D) Atropine
D) Atropine
A nurse is documenting the results of assessment of a patient w/bronchiectasis. What would the nurse most likely include in documentation? A) Sudden onset of pleuritic chest pain B) Wheezes on auscultation C) Increased anterior-posterior (A-P) diameter D) Clubbing of the fingers
D) Clubbing of the fingers
A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take? A) Check the tubing connections for leaks B) Check the suction control outlet on the wall C) Clamp the chest tube D) Continue to monitor the client's respiratory status
D) Continue to monitor the client's respiratory status
A patient has been dx w/HF that has not yet responded to tx. What breath sound should the nurse expect to assess on auscultation? A) Expiratory wheezes B) Inspiratory wheezes C) Rhonchi D) Crackles
D) Crackles
The nurse is admitting a patient to the medical surgical unit from the PACU. What should the nurse do to help the patient clear secretions + help prevent pneumonia? A) Encourage the patient to eat a balanced diet that is high in protein B) Encourage the patient to limit his activity for the first 72 hr C) Encourage the patient to take his medications as ordered D) Encourage the patient to use the incentive spirometer every 2 hr
D) Encourage the patient to use the incentive spirometer every 2 hr
The nurse receives a phone call from a clinic patient who experienced fever + slight dyspnea several hours after receiving the pneumococcal vaccine. What is the nurse's most appropriate action? A) Instruct the patient to call 911. B) Inform the patient that this is an expected response to vaccination. C) Encourage the patient to take NSAIDs until symptoms are relieved. D) Ensure that the adverse reaction is reported.
D) Ensure that the adverse reaction is reported.
The nurse's aide notifies the nurse that a patient has decreased oxygen saturation levels. The nurse assesses the patient + finds that he is tachypnic, has crackles on auscultation, + his sputum is frothy + pink. The nurse should suspect what complication? A) Pulmonary embolism B) Atelectasis C) Laryngospasm D) Flash Pulmonary Edema
D) Flash Pulmonary Edema
A patient is scheduled to have excess pleural fluid aspirated w/a needle in order to relieve her dyspnea. The patient inquires about the normal function of pleural fluid. What should the nurse describe? A) It allows for full expansion of the lungs w/in the thoracic cavity. B) It prevents the lungs from collapsing w/in the thoracic cavity C) It limits lung expansion w/in the thoracic cavity D) It lubricates the movement of the thorax + lungs
D) It lubricates the movement of the thorax + lungs
A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min + become irregular. Which of the following actions should the nurse take? A) Obtain a cardiology consult. B) Suction the client less frequently. C) Administer an antidysrhythmic medication. D) Perform pre-oxygenation prior to suctioning.
D) Perform pre-oxygenation prior to suctioning.
To improve the oxygenation of a client w/ARDS who is receiving mechanical ventilation, the nurse should place the client in which position? A) Supine B) Semi-Fowler's C) Lateral side D) Prone
D) Prone
A patient in the ICU is status post embolectomy after a pulmonary embolus. What assessment parameter does the nurse monitor most closely on a patient who is postoperative following an embolectomy? A) Pupillary response B) Pressure in the vena cava C) White blood cell differential D) Pulmonary arterial pressure
D) Pulmonary arterial pressure
A nurse is caring for a client who has active pulmonary TB + a new prescription for IV rifampin. The nurse should instruct the client that they should expect to experience which of the following manifestations while taking this medication? A) Constipation B) Black-colored stools C) Staining of teeth D) Red-colored urine
D) Red-colored urine
A nurse is planning the care of a patient w/emphysema who will soon be d/c. What teaching should the nurse prioritize in the POC? A) Taking prophylactic antibiotic as ordered B) Adhering to the tx regimen in order to cure the disease C) Avoiding airplanes, buses, + other crowded public places D) Setting realistic short-term + long-range goals
D) Setting realistic short-term + long-range goals
A nurse is providing health education to the family of a patient w/bronchiectasis. What should the nurse teach the patient's family members? A) The correct technique for chest palpation + auscultation B) Techniques for assessing the patient's fluid balance C) The technique for providing deep nasotracheal suctioning D) The correct technique for providing postural drainage
D) The correct technique for providing postural drainage
The nurse is caring for a patient who has been scheduled for a bronchoscopy. How should the nurse prepare the patient for this procedure? A) Administer a bolus of IV fluids B) Arrange for the insertion of a peripherally inserted central catheter C) Administer nebulized bronchodilators every 2 hours until the test D) Withhold food + fluids for several hours before the test
D) Withhold food + fluids for several hours before the test
What is a typical complication of inadequate chest tube dressing changes? A) Increased blood lactic acid B) Activation of clotting factors C) Increased intra-abdominal pressure D) Increased heart rate E) No PR interval F) Infection
F) Infection
Dyspnea; what all can cause it and what are the S/S of those manifestations
S/S of atelectasis 🚨Quality + Safety Nursing Alert 🚨 Tachypnea, dyspnea, + mild-to-moderate hypoxemia are hallmarks of the severity of atelectasis. S/S of PCP aspiration is inhalation of foreign material (oropharyngeal or stomach contents) into the lungs. Serious complications that can cause pneumonia + result in the following clinical picture: tachycardia, dyspnea, central cyanosis, HTN, hypotension, + potentially death TB clinical manifestation of lung abscess. clinical manifestation of sarcoidosis clinical manifestation of pleural effusion thoracentesis is performed to remove fluid, to abstain a specimen for analysis + to relieve dyspnea + respiratory compromise Pulmonary HTN may be suspected in a patient w/dyspnea w/exertion w/out other clinical manifestations lung cancer (Bronchogenic Carcinoma) dyspnea is prominent in patients early in their disease. causes of dyspnea may include tumor occlusion of the airway or lung parenchyma, pleural effusion, pneumonia, or complications of treatment Lung Volume Reduction - surgical procedure involving the removal of 20% to 30% of a patient's lung through a midsternal incision or video thoracoscopy. The diseased lung is identified on a lung perfusion scan. This surgery leads to significant improvements in dyspnea, exercise capacity, quality of life, + survival of a subgroup of people w/end-stage emphysema. Radiation therapy may help relieve cough, chest pain, dyspnea, hemoptysis, + bone + liver pain.
The best method for the nurse to use in order to administer oxygen to a COPD patient
The VENTURI mask is used primarily for patients w/COPD b/c it can accurately provide appropriate levels of supplemental oxygen (avoiding the risk of suppressing the hypoxic drive).
The structures located in the lower respiratory tract.
The lower respiratory tract consists of the lungs which contain: bronchial + alveolar structures needed for gas exchange. Lungs, pleura, mediastinum, bronchi + bronchioles, + alveoli.
The best method to treat ARDS
The primary focus in the management of ARDS includes identification + tx of the underlying condition. Therapy almost always includes ET intubation + mechanical ventilation. In addition, circulatory support, adequate fluid volume, + nutritional support are important. Supplemental oxygen is used as the patient begins the initial spiral of hypoxemia. As the hypoxemia progresses, intubation + mechanical ventilation are instituted. Providing ventilatory PEEP support is a critical part of the tx of ARDS. PEEP usually improves oxygenation, but it does not influence the natural hx of the syndrome. Helps increase functional residual capacity + reverse alveolar collapse by keeping the alveoli open, resulting in improved arterial oxygenation + a reduction in the severity of the V./Q. imbalance. By using PEEP, a lower FiO2 may be required. The goal is a PaO2 greater than 60 mm Hg or an oxygen saturation level of greater than 90% at the lowest possible FiO2. Systemic hypotension may occur in ARDS as a result of hypovolemia secondary to leakage of fluid into the interstitial spaces + depressed CO from high levels of PEEP therapy. Hypovolemia must be carefully treated w/out causing further overload. Inotropic or vasopressor agents may be required. Additional supportive tx may include prone positioning, sedation, paralysis, + nutritional support. No specific pharmacologic tx of ARDS, except supportive care. Neuromuscular blocking agents, sedatives, + analgesics may be used to improve patient-ventilator synchronization + help to decrease severe hypoxemia. Inhaled nitric oxide (an endogenous vasodilator) was thought to reduce V./Q. mismatch + improve oxygenation; however, findings from clinical trials have not shown an improvement in mortality rates between patients who did + did not receive nitric oxide. Adequate nutritional support is vital in the tx of ARDS. Patients w/ARDS require 35 to 45 kcal/kg/day to meet caloric requirements. Enteral feeding is the first consideration; however, parenteral nutrition also may be required. These patients will be intubated. Once you reach a PEEP past 7 you are at risk for messing up the lungs, + should not be allowed to cough. Will be doing a lot of diuretics, maybe a lot of protein.
Clinical presentation of pulmonary edema.
occurs due to damage of the pulmonary capillary lining May be due to direct injury to the lung (sepsis, pancreatitis, multiple transfusions, cardiopulmonary bypass), or injury plus elevated hydrostatic pressures. Hypoxemia may persist despite high concentrations of supplemental oxygen, due to the intrapulmonary shunting of blood. S/S = agitated, pale or cyanotic, skin clammy + cool, use of accessory muscles, distended neck veins, RR >30, orthopnea, tachycardia, decreased SAO2 (typically <90%), chest pain, wheezing, coughing, crackles, wheezes, rhonchi, pink, frothy, blood-tinged sputum
In-line suctioning, how long for a rest period between suctions? What will you document? Do you give additional O2 (100%) before suctioning? - only for intubated patients
rest period = 1 min, only suction for 10-20 seconds document = toleration, color, consistency
Gimme all your knowledge on chest tubes...... GO
the use of a chest tube + closed drainage system to re-expand the lung + to remove excess air, fluid, or blood chest tubes + a closed drainage system are used to re-expand the involved lung + to remove excess air, fluid, + blood + may be used in patients who have had a thoracotomy. Chest drainage systems also are frequently indicated in the tx of spontaneous pneumothorax + trauma resulting in pneumothorax. The normal breathing mechanism operates on the principle of negative pressure. The pressure in the chest cavity normally is lower than the pressure of the atmosphere, causing air to move into the lungs during inspiration. Whenever the chest is opened, there is a loss of negative pressure, which results in collapse of the lung. The collection of air, fluid, or other substances in the chest can compromise cardiopulmonary function + can also cause the lung to collapse. Pathologic substances that can collect in the pleural space include fibrin or clotted blood, liquids (serous fluids, blood, pus, chyle) + gasses (air from the lung, tracheobronchial tree, or esophagus). Chest tubes may be inserted to drain fluid or air from any of the three compartments of the thorax (the right + left pleural spaces + the mediastinum). The pleural space, located between the visceral + parietal pleura, normally contains 20 mL or less of fluid, which helps lubricate the visceral + parietal pleura. There are 2 types of chest tubes: small-bore + large-bore catheters. Small-bore catheters (7 Fr to 12 Fr) have a one-way valve apparatus to prevent air from moving back into the chest. They can be inserted through a small skin incision. Large-bore catheters, which range in size up to 40 Fr, are usually connected to a chest drainage system to collect any pleural fluid + monitor for air leaks. After the chest tube is positioned, it is sutured to the skin + connected to a drainage apparatus to remove the residual air + fluid from the pleural or mediastinal space. This results in the re-expansion of remaining lung tissue. Traditional Water Seal (aka wet suction) - has 3 chambers; a collection chamber, water-seal chamber (middle chamber), + wet suction control chamber. Requires that sterile fluid be instilled into water seal + suction chambers. Has positive + negative-pressure release valves. Intermittent bubbling indicates that the system is functioning properly. Additional suction can be added by connecting the system to a suction source. Dry Suction Water Seal (aka dry suction) - has 3 chambers; a collection chamber, water-seal chamber (middle chamber), + suction regular dial. Requires that sterile fluid be instilled in a water-seal chamber at 2-cm level. No fluid-filled suction chamber. Suction pressure is set w/a suction regulator dial. Has positive- and negative-pressure release valves. Has an indicator to signify that the suction pressure is adequate. Quitter than traditional water-seal systems. Dry Suction (aka one-way valve system) - Has a one-way mechanical valve that allows air to leave the chest + prevents air from moving back into the chest. No need to fill the suction chamber w/fluid; thus, can be set up quickly in an emergency. Works even if knocked over, making it ideal for patients who are ambulatory.
