ATI Dynamic Quiz Respiratory

a nurse is caring for a client who is scheduled to have his chest tube removed. Which of the following actions should the nurse take? A. cover the insertion site with a hydrocolloid dressing after removal. B. Provide pain meds immediately after removal. C. Instruct the patient to perform the Valsalva maneuver during removal. D. Delegate removal of the chest tube to a LPN.

C. instruct the patient to perform the Valsalva maneuver during removal. Rationale: To maintain the appropriate amount of negative pressure in the chest in order to prevent air entry into the pleural space. Incorrect answers: The nurse should cover the insertion site with occlusive dressing to prevent air entry into the pleural space. The nurse should provide the client with pain meds prior to the procedure to promote comfort during the removal of the chest tube. The nurse should expect a provider or specially trained RN to remove the chest tube. The nurse should not delegate this procedure to an LPN, as it is beyond the LPN's scope of practice.

A nurse in the ED is assessing a client for closed pneumothorax and significant bruising of the left chest following a motor vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax? A. Absence of breath sounds. B. expiratory wheezing C. inspiratory stridor D. Rhonchi

A. Absence of breath sounds. Rationale: a client who has pneumothorax experiences severely diminished or absent breath sounds on the affected side. Incorrect Answers: A client who has asthma experiences expiratory wheezing during an acute asthma attack. A client who has an airway obstruction experiences inspiratory stridor, which is a loud crowing-like sound that is often heard without a stethoscope. A client who has thick sputum production or obstruction from a foreign body has rhonchi, which are dry, low-pitched, snoring like noises produced in the throat.

A nurse on a med-surg unit is caring for 4 patients. Which of the following clients should the nurse monitor for crepitus? A. A client who has a chest tube following a pneumothorax. B. A client who has an acute exacerbation of Crohn's disease. C. A client who is post op following a laparoscopic appendectomy D. A client who is recovering from thyroid storm.

A. a client who has a chest tube following a pneumothorax. Rationale: crepitus, a crackling sound resulting from air trapped under the skin, can be palpated following a pneumothorax. The nurse should report the finding to the provider. Incorrect answers: a client with Crohn's is not at risk for crepitus. Crohn's disease is an inflammatory disorder of the small intestine. A client who is post op following a laparoscopic appendectomy is not at risk for crepitus because the surgery is minimally invasive. A client who is recovering from thyroid storm is not at risk for crepitus. Thyroid storm results in fever, tachycardia, and hypertension from the excessive release of thyroid hormone.

A nurse is caring for a client who is post op following a thoracic lobectomy. The client has 2 chest tubes in place: 1 in the lower portion of the thorax and the other higher on the chest wall. When a family member asks why the client has 2 chest tubes, which of the following responses should the nurse make? A. "two tubes were necessary due to excessive bleeding from the area of the surgery." B. "the tubes drain from 2 different lung areas." C. "the lower tube will drain blood and the higher tube will remove air." D. "The second tube will take over if blood clots block the first tube."

C. "The lower tube will drain blood, and the higher tube will remove air." Rationale: the tube that is lower will drain blood, and the tube that is higher will allow for removal of air. Incorrect answers: excessive bleeding indicates complication that the surgeon must address. Blood typically drains from the base of the lung, not the apex. If a tube becomes blocked, the nurse should report it to the surgeon and prepare to attempt to re-establish patency or remove and replace the tube.

A client is admitted to the ED following a motorcycle crash. The nurse notes a crackling sensation upon palpation of the right side of the client's chest. After notifying the provider, the nurse should document this finding as which of the following? A. Friction rub B. crackles C. crepitus D. tactile femitus

C. Crepitus Rationale: Crepitus, also called subcutaneous emphysema, is a course crackling sensation that the nurse can feel when palpating the skin surface over the client's chest. Crepitus indicates an air leak into the subcutaneous tissue, which is often a clinical manifestation of pneumothorax. Incorrect answers: a friction rub is a scratching or squeaking sound heard when auscultating the client's lungs. This condition occurs due to the pleural surfaces rubbing together. A friction rub is a clinical manifestation of pleurisy. Crackles (sometimes called rales) are wet, popping sounds heard when auscultating the client's lungs. This condition occurs when fluid is present in the client's airways or alveoli. Crackles are a clinical manifestation of pneumonia. Tactile fremitus is a vibration of the chest wall that the nurse can feel when palpating the client's chest as the client repeats a syllable such as "nine, nine." Increased tactile fremitus is a clinical manifestation of pneumonia.

A nurse is planning care for a client following placement of a chest tube 1 hour ago. Which of the following actions should the nurse include in the plan of care? A. Clamp the chest tube if there is continuous bubbling in the water seal chamber. B. Keep the chest tube drainage system at the level of the right atrium. C. Tape all connections between the chest tube and drainage system. D. Empty the collection chamber and record the amount of drainage every 8 hours.

C. Tape all connections between the chest tube and drainage system. Rationale: the nurse should tape all connections to ensure that the system is airtight and prevent the chest tubing from accidently disconnecting. Incorrect Answers: The nurse should expect bubbling in the water seal chamber on forced expiration or coughing, which is an indication that the system is working properly. Additionally the nurse should avoid clamping the chest tube unless the drainage unit needs to be replaced or an air leak must be located. The nurse should ensure the chest tube drainage system is below the level of the chest at all times to facilitate proper drainage by gravity. The nurse should not empty the collection chamber or change the system unless it is almost full.

a nurse is caring for a client following a right pleural thoracentesis. The nurse measures a total of 35ml of purulent drainage. Which of the following findings should the nurse recognize as an indication of a tension pneumothorax? SATA A. Tracheal deviation to the left B. Temp of 38.8C (102F) C. Absent breath sounds D. Neck Vein Deviation E. Bradypnea

Correct Answers: A Tracheal deviation to the left. C. Absent Breath sounds on the right side. D. Neck vein distension Rationale: A tension pneumothorax can occur following a thoracentesis. A trachea that is deviated to the unaffected side instead of being in the center of the neck is a manifestation of pneumothorax. Absent breath sounds on the affected side and neck vein distention are also manifestations of a pneumothorax. As the client's difficulty breathing increases, the blood flow return compresses, causing the neck veins to distend. Incorrect Answers: An elevated temp is a sign of an infection and can be associated with the purulent drainage obtained. However, this is not a manifestation of a pneumothorax. Clients who experience a tension pneumothorax exhibit respiratory distress and tachypnea until a chest tube is inserted to re-inflate the lung.

A nurse is providing post op care for a client who has 2 chest tubes in place following a lobectomy. The client asks the nurse the reason for having 2 chest tubes. The nurse should inform the client that the lower chest tube is placed for which of the following reasons? A. Removing air from the pleural space. B. creating access for irrigating the chest cavity. C. Evacuating secretions from the bronchioles and alveoli. D. Draining blood and fluid from the pleural space.

D. Draining blood and fluid from the pleural space. Rationale: The nurse should inform the client that blood and fluids tend to accumulate in the bases and posterior areas of the pleural cavity following a lobectomy. For this reason, the lower chest tube primarily drains blood and fluid from the pleural space. Incorrect answers: The upper chest tube removes air from the pleural space. The chest tubes are not used for irrigation following a lobectomy. Secretions are removed from the airways via tracheal suctioning rather that chest tubes.

A nurse is caring for a client who has a chest tube. The nurse notes that the chest tube has become disconnected from the chest drainage system. Which of the following actions should the nurse take? A. Place the drainage system at the head of the client's bed. B. increase the suction to the chest drainage system. C. place the client on low-flow oxygen via. nasal cannula. D. immerse the end of the chest tube in a bottle of sterile water.

D. Immerse the end of the chest tube in a bottle of sterile water. Rationale: if the chest tube and drainage system have become disconnected, air can enter the pleural space, producing a pneumothorax that can result in severe respiratory distress. To prevent a pneumothorax from developing, a temp water seal can be established by immersing the end of the chest tube in an open bottle of sterile water. This allows air to escape and not enter the pleural space. A bottle of sterile water should always be readily available at the bedside for a client who has a chest tube. Incorrect Answers: The drainage system should never be placed above the level of the client's chest. The system should be placed below the level of the client's chest to allow gravity to drain the fluid from the chest cavity. Increasing the suction to the chest drainage system will not assist the client's breathing at this time because the chest tube has been disconnected. Applying oxygen will not assist the client's breathing at this time because the chest tube has become disconnected.

A nurse is preparing a client for thoracentesis. In which of the following positions should the nurse place the client? A. Lying flat on the affected side B. Prone with the arms raised over the head. C. Supine with the head of the bed elevated. D. Sitting while leaning forward over the bedside table.

D. Sitting while leaning forward over the bedside table. Rationale: This position maximizes the space between the client's ribs and allows aspiration of the accumulated fluid and air. Incorrect answers: Lying flat on the affected side does not allow access for draining the accumulated fluid and air. Prone position does not allow access for draining the accumulated fluid and air. A supine position does not allow access for draining the accumulated fluid and air.

A client comes to the ED in severe respiratory distress following left-sided blunt chest trauma. The nurse 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? A. Tracheostomy placement B. Thoracentesis C. CT scan of the chest D. Chest tube insertion

D. chest tube insertion. Rationale: the client's manifestations indicate pneumothorax due to blunt chest trauma. The nurse should prepare for the provider to insert a chest tube and connect it to a water-seal drainage system. Incorrect Answers: The client might require mechanical ventilation to stabilize the respiratory status; however, there is no indication at this time for a tracheostomy. A thoracentesis is indicated for a client who has an increase in pleural fluid due to cancer, pleurisy, or TB or for a client who requires microscopic examination of the pleural fluid. While the client will require several portable chest x-rays, there is no immediate indication for a CT scan of the chest.