CHEST TUBE, TRACHEOSTOMY ETC..
4
The nurse caring for a client who has a pneumothorax notes continuous bubbling in the water seal chamber of the client's closed-chest drainage system. How should the nurse interpret this finding? 1.The drainage chamber is full. 2.The pneumothorax is resolving. 3.The suction chamber system is shut off. 4.There is an air leak somewhere in the system
2
Which should the nurse do when caring for a client with a chest tube attached to a chest drainage system? 1.Empty the drainage collection chamber every shift. 2.Ensure the water level in the water seal chamber is at the 2-cm level. 3.Maintain the drainage collection device at the level of the client's chest. 4.Clamp the chest tube before moving the client from the bed to the chair
4
A client being mechanically ventilated after experiencing a fat embolism is visibly anxious. What is the best nursing action? 1.Ask a family member to stay with the client at all times. 2.Ask the health care provider for a prescription for succinylcholine. 3.Encourage the client to sleep until arterial blood gas results improve. 4.Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed
4
A client is on continuous mechanical ventilation (CMV) and the high-pressure alarm sounds. Which action should the nurse take to eliminate the problem? 1.Silence the alarm to avoid disturbing the client. 2.Check the ventilator circuit for any disconnections. 3.Inflate the cuff of the endotracheal tube to a pressure of 25 mm Hg. 4.Empty excess accumulated water from the ventilatory circuit tubing
2
A client is on continuous mechanical ventilation (CMV), and the low-pressure alarm sounds. The nurse should take which action? 1.Make sure that the client is not lying on the ventilator tubing. 2.Determine if there are any disconnections in the ventilator tubing. 3.Check to see if the client is biting on the endotracheal tube (ETT). 4.Auscultate the lungs to determine if the client needs to be suctioned.
2
The 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
1
The nurse is assisting in caring for a client after removal of an endotracheal tube. Which finding should be reported to the health care health care provider (HCP) immediately? 1.Stridor 2.Lung congestion 3.Occasional pink-tinged sputum 4.Respiratory rate of 26 breaths/min
3
The nurse is caring for a client with a chest tube drainage system. The nurse notes a fluctuating water level on inspiration and expiration in the submerged tube in the water seal chamber of the chest tube drainage system. Which nursing action is appropriate? 1.Suction the client. 2.Increase the suction. 3.Document the findings. 4.Encourage coughing and deep breathing
1,5
The nurse is caring for a client with a dry suction chest drainage system. During assessment of the drainage system, what should the nurse expect to find? Select all that apply. 1.The dry suction control regulation set to the prescribed amount 2.The water filled suction control chamber filled to the prescribed amount 3.Increased intermittent bubbling in the water seal chamber when the system is to gravity 4.Continuous bubbling in the water seal chamber when the system is connected to suction 5.The drainage in the collection chamber marked each shift to monitor the amount of drainage
3
The nurse should determine that tracheal suctioning is needed if which is noted? 1.Arterial oxygen level of 90 mm Hg 2.2 hours elapsed since the last suctioning 3.Congested breath sounds in the lung fields 4.Respiratory rate of 18 breaths/min, up from 16 breaths/min
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 monitoring a client who has a closed chest tube drainage system. The nurse notes fluctuation of the fluid level in the water seal chamber during inspiration and expiration. On the basis of this finding, the nurse should make which interpretation? 1.There is a leak in the system. 2.The chest tube is functioning as expected. 3.The amount of suction needs to be decreased. 4.The occlusive dressing at the insertion site needs reinforcement.
4
A client with an endotracheal tube attached to mechanical ventilation begins to cough, and the client's face appears flushed. Which action should the nurse take first? 1.Call respiratory therapy. 2.Contact the health care provider. 3.Check the client's blood pressure. 4.Suction the client through the endotracheal tube
4
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
1
client has been treated for pleural effusion with a thoracentesis. The nurse determines that this procedure has been effective if the nurse notes which assessment finding? 1.Absence of dyspnea 2.Increased severity of cough 3.Dull percussion notes over lung tissue 4.Decreased tactile fremitus over lung tissue
2
The nurse assesses for one-sided chest movement on the right while a client is being intubated by the health care provider. Which could occur with the endotracheal tube? 1.It could enter the left main bronchus if inserted too far. 2.It could enter the right main bronchus if inserted too far. 3.It could enter the left main bronchus if not inserted far enough. 4.It could enter the right main bronchus if not inserted far enough
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%
4
The nurse determines that the client with a chest tube to a closed drainage system is experiencing an air leak. Which finding is indicative of this? 1.Tidaling is absent. 2.Gentle bubbling is observed in the suction control chamber. 3.Vacillation of water in the water seal chamber occurs during respiration. 4.Continuous bubbling is observed in the water seal chamber during inspiration and expiration.
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.
3
The nurse is assisting a radiologist to facilitate a thoracentesis. The nurse assists the client to a position that widens the spaces between the ribs to help drain which area? 1.Alveoli 2.Trachea 3.Pleural space 4.Main bronch
4
The nurse is assisting the health care provider (HCP) with insertion of a chest tube. The nurse notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this observation, the nurse should take which action? 1.Ensure that suction is turned on. 2.Reinforce the occlusive dressing. 3.Encourage the client to breathe deeply. 4.Document the accurate functioning of the tube.
2
The nurse is caring for a client with a chest tube drainage system and notes constant bubbling in the water seal chamber. Which nursing action is appropriate? 1.Reposition the client. 2.Notify the health care provider (HCP). 3.Change the chest tube drainage system. 4.No action is necessary because this is a normal, expected finding
