Chapter 21

A patient recovering from thoracic surgery is on a long-term mechanical ventilation and becomes very frustrated when he tries to communicate. What intervention should the nurse perform to assist the patient?

Express empathy and then encourage that patient to write, use a pictured board, or spell words with an alphabet board

A nurse is teaching a patient how to perform flow type incentive spirometry prior to his schedule thoracic surgery/ What instruction should the nurse provided to the patient?

" Breathe in deeply through the spirometer, hold your breath briefly, and then exhale

A patient in the ICU has had an endotreacheal tube in place for 3 weeks. The physician has ordered that a trachesotomy tube be placed. The patient's family wants to know why the endotracheal tube cannot be left in place. What would be the nurse's best response?

"When an endotracheal tube is left in too ling it can damage the lining of the windpipe"

A patient is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching includes what?

Correct use of incentive spirometry

The nurse is discussing activity of management with a patient who is postoperative following thoracotomy. What instruction should the nurse give to the patient regarding activity immediately following discharge?

Perform should exercises five time daily

The nurse is caring for a patient who is ready to be weaned for the ventilator. In preparing to assist in the collaborative process of weaning the patient from a ventilator, the nurse is aware that the weaning of the patient will progress in what order?

Removal from the ventilator, tube, and then oxygen

The home care nurse is visiting a patient newly discharged home after a lobectomy. What would be most important for the home care nurse to assess?

Signs and symptoms of respiratory complications

The home care nurse is assessing a patient who requires home oxygen therapy. What criterion indicates that an oxygen concentrator will best meet the needs of the patient in the home environment?

The patient desires a portable oxygen delivery system the can deliver 2L/min

A patient with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the physician to order>

Venturi mask

A patient has been discharged home after thoracic surgery. The home care nurse performs the initial visit and finds the patient discouraged and saddened. The client states, "I am recovering so slowly. I really thought I would be better by now." What nursing action should the nurse prioritize?

Provide emotional support to the patient and family

The nurse has explained to the patient that after his thoracotomy, it will be important to adhere to a coughing schedule. What would be an appropriate nursing intervention for this client?

Teach him how to perform huffing

The OR nurse is setting up a water-seal chest drainage system for a patient who has just has a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system>

20 cm H2O

A patient's plan of care specifies postural drainage. What action should the nurse perform when providing this noninvasive therapy?

Assist the patient into a position that will allow gravity to move secretions

Postural drainage has been ordered for a patient who is having difficulty mobilizing her bronchial secretions. Before repositioning the patient and beginning treatment, the nurse should perform what health assessment?

Chest auscultation

The nurse is assessing a patient who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in that water seal rises and falls in rhythm withthe patient;s respiration. How should the nurse best respond to this assessment finding?

Document that the chest drainage system is operating as it is intended

The nurse is performing patient education for a patient who is being discharged on mini-nebulizer treatments. What information should the nurse prioritize in the patient's discharge teaching?

How to perform diaphragmatic breathing

The nurse is caring for a patient who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. What method of oxygen delivery is most appropriate for the patient's needs?

Nasal cannula

A nurse educator is reviewing the indications for chest drainage systems with group of medical nurses. What indications should the nurses identify? Select all that apply.

Post thoracotomy Spontaneous pneumothorax Chest trauma resulting in pneumothorac

The critical care nurse and the other members of the care team are assessing the patient to see if he is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify?

Stable vital signs and ABGs

The nurse is caring for a patient with an endotracheal tube recognizes several disadvantage of an endotracheal tube. What would the nurse recognize as a disadvantage pf endotracheal tubes?

To cough reflex is depressed

What would the critical care nurse recognize as a condition that may indicate a patient's need to have a tracheostomy?

A patient requires permanent ventilation

The nurse is preparing to suction a patient with an endotracheal tube. What should be the nurse's first step in the suctioning process?

Assess the patient's lung sounds and SAO2 via pulse oximeter

The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess>

Baseline arterial blood gas (ABG) levels

The nurse is caring for a client with an endotracheal tube who is on a ventilator. When assessing the client, the nurse knows to maintain what cuff pressure to maintain appropriate pressure on the tracheal wall?

Between 15 and 20 mm Hg

The home care nurse is planning to begin breathing retraining exercises with a client newly admitted to the home health service. The home care nurse knows that breathing retraining is especially indicated if the patient has what diagnosis?

COPD

The physician has ordered continuous positive airway pressure (CPAP) with the delivery of a patient's high-flow oxygen therapy. The patient asks the nurse what the benefit of CPAP is. What would be the nurse's best response?

CPAP allow a lower percentage of oxygen to be used with a similar effect

The nurse is preparing to discharge a patient after thoracotomy. The patient is going home on oxygen therapy and requires wound care. As a result, he will receive home care nursing. What should the nurse include in the drainage teaching for this patient?

Correct and safe use to oxygen therapy equipment

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient has been receiving high-flow oxygen therapy for an extended time. What symptoms should the nurse anticipate if the patient were experiencing oxygen toxicity?

Dyspnea and substernal pain

The nurse is caring for a patient who is scheduled to have a thoracotomy. When planning preoperative teaching, what information should the nurse communicate to the patient?

How to splint in incision when coughing

A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this patient is necessary. What is the main rationale for this?

Maintaining a patent airway

A nurse has performed tracheal suctioning on a patient who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention>

Measure the patient's oxygen saturation

The medical nurse is creating the care plan of an adult patient requiring mechanical ventilation. What nursing action is most appropriate?

Monitor cuff pressure every 8 hours

The critical care nurse is percepting a new nurse on the unit. Together that are caring for a patient who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff?

Monitor the pressure in the cuff at least every 8 hours

The nurse has admitted a patient who is scheduled for a thoracic resection. The nurse is providing preoperative teaching and is discussing several diagnostic studies that will be required prior to surgery. Which study will be performed to determine whether the planned resection will leave sufficient functioning lung tissue?

Pulmonary function studies

A nurse is educating a patient in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell that patient and the family that this drainage system is used for?

Removing excess air and fluid

The decision has been made to discharge a ventilator-dependent patient home. The nurse is developing a teaching plan for this patient and his family. What would be the most important to include in this teaching plan?

Signs of pulmonary infection

A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube?

To remove air from the pleural space

The nurse is performing nasotracheal suctioning on a medical patient and obtains copious amounts of secretions from the patient's airway, even after inserting and withdrawing the catheter several times. How should the nurse proceed>

Wait several minutes and then repeat suctioning

While caring for a patient with an endotracheal tube, the nurse recognizes that suctioning is required how often?

When adventitious breath sounds are auscultated

While assessing the patient. the nurse observes constant bubbling in the water-seal chamber of the patient's closed chest-drainage system. What should the nurse conclude?

The system has an air leak