chapter 21 prepu
The nurse received a client from the post-anesthesia care unit (PACU) who has a chest tube to a closed drainage system. Report from the PACU nurse included drainage in the chest tube at 80 mL of bloody fluid. Fifteen minutes after transfer from the PACU, the chest tube indicates drainage as pictured. The client is reporting pain at "8" on a scale of 0 to 10. The first action of the nurse is to: Administer prescribed pain medication. Notify the physician. Lay the client's head to a flat position. Assess pulse and blood pressure.
Assess pulse and blood pressure. The client has bled 120 mL of bloody drainage in the chest drainage system within 15 minutes. It is most important for the nurse to assess for signs and symptoms of hemorrhage, which may be indicated by a rapid pulse and decreasing blood pressure. The nurse may then lay the client in a flat position and notify the physician.
Question 5 of 10 A client with COPD has been receiving oxygen therapy for an extended period. What symptoms would be indicators that the client is experiencing oxygen toxicity? Select all that apply. Fatigue Dyspnea Substernal pain Mood swings Bradycardia SUBMIT ANSWER Exit quiz
Fatigue Dyspnea Substernal pain
A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition? Delirium Hyperventilation Semiconsciousness Hypoxia
Hypoxia As the respiratory center in the brain becomes depressed, hypoxia occurs, producing wheezing, bradycardia, and a decreased respiratory rate. Delirium is a state of mental confusion characterized by disorientation to time and place. Hyperventilation (respiratory rate greater than that metabolically necessary for gas exchange) is marked by an increased respiratory rate or tidal volume, or both. Semiconsciousness is a state of impaired consciousness characterized by limited motor and verbal responses and decreased orientation.
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? Suction the client's artificial airway. Increase the oxygen percentage. Check for an apical pulse. Ventilate the client with a handheld mechanical ventilator.
Suction the client's artificial airway. A high-pressure alarm on a continuous mechanical ventilator indicates an obstruction in the flow of oxygen from the machine to the client. The nurse should suction the client's artificial airway to remove respiratory secretions that could be causing the obstruction. The sounding of a ventilator alarm has no relationship to the apical pulse. Increasing the oxygen percentage and ventilating with a handheld mechanical ventilator wouldn't correct the airflow blockage.
Question 1 of 10 Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. This therapy may be used for a client with: a malignant tumor. pneumonia. hyperthermia. a compromised skin graft.
a compromised skin graft. A client with a compromised skin graft could benefit from hyperbaric oxygen therapy because increasing oxygenation at the wound site promotes wound healing. Hyperbaric oxygen therapy isn't indicated for malignant tumors, pneumonia, or hyperthermia.
A nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority? Assessing the client's respiratory status, orientation, and skin color Applying an oil-based lubricant to the client's mouth and nose Posting a "No smoking" sign over the client's bed Changing the mask and tubing daily
Assessing the client's respiratory status, orientation, and skin color
A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse Contacts the respiratory therapy department to report the ventilator is malfunctioning Consults with the physician about removing the client from the ventilator Continues assessing the client's respiratory status frequently Changes the setting on the ventilator to increase breaths to 14 per minute
Continues assessing the client's respiratory status frequently The SIMV setting on a ventilator allows the client to breathe spontaneously with no assistance from the ventilator for those extra breaths. Data in the stem suggest that the ventilator is working correctly. The nurse would continue making frequent respiratory assessments of the client. There are not sufficient data to suggest the client could be removed from the ventilator. There is no reason to increase the ventilator's setting to 14 breaths per minute or to contact respiratory therapy to report the machine is not working properly.
Which type of oxygen therapy includes the administration of oxygen at pressure greater than 1 atmosphere? High-flow systems Transtracheal Hyperbaric Low-flow systems
Hyperbaric
Question 8 of 10 The nurse has instructed a patient on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which of the following? Promote the patient's ability to intake oxygen Improve oxygen transport, induce a slow, deep breathing pattern, and assist the patient to control breathing Promote the strengthening of the patient's diaphragm Promote a more efficient and controlled ventilation and to decrease the work of breathing
Improve oxygen transport, induce a slow, deep breathing pattern, and assist the patient to control breathing
Which of the following would indicate a decrease in pressure with mechanical ventilation? Plugged airway tube Kinked tubing Increase in compliance Decrease in lung compliance
Increase in compliance
A patient is being mechanically ventilated with an oral endotracheal tube in place. The nurse observes that the cuff pressure is 25 mm Hg. The nurse is aware of what complications that can be caused by this pressure? (Select all that apply.) Tracheal ischemia Pressure necrosis Hypoxia Tracheal bleeding Tracheal aspiration
Pressure necrosis Tracheal bleeding Tracheal aspiration Complications can occur from pressure exerted by the cuff on the tracheal wall. Cuff pressures should be maintained between 15 and 20 mm Hg (Morton, Fontaine, Hudak, et al., 2009). High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis, whereas low cuff pressure can increase the risk of aspiration pneumonia. Routine deflation of the cuff is not recommended because of the increased risk of aspiration and hypoxia.
The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient? The patient is in a hypermetabolic state. The patient is having a myocardial infarction. The patient is having a stress reaction. The patient is hypoxic from suctioning.
The patient is hypoxic from suctioning. Apply suction while withdrawing and gently rotating the catheter 360 degrees (no longer than 10-15 seconds). Prolonged suctioning may result in hypoxia and dysrhythmias, leading to cardiac arrest.
A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? The system is functioning normally. The system has an air leak. The chest tube is obstructed. The client has a pneumothorax.
The system has an air leak.
Which of the following is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means? Partial-rebreathing mask Venturi mask T-piece Nasal cannula
Venturi mask The Venturi mask is the most reliable and accurate method for delivering a precise concentration of oxygen through noninvasive means. The mask is constructed in a way that allows a constant flow of room air blended with a fixed flow of oxygen. Nasal cannula, T-piece, and partial-rebreathing masks are not the most reliable and accurate methods of oxygen administration.
A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside? Water-seal chest drainage set-up Oxygen analyzer Tracheostomy cleaning kit Manual resuscitation bag
Manual resuscitation bag
The nurse is preparing to perform chest physiotherapy (CPT) on a patient. Which of the following patient statements would indicate the procedure is contraindicated. "I have been coughing all morning and am barely bringing anything up." "I just changed into my running suit; we can do my CPT now." "I just finished eating my lunch, I'm ready for my CPT now." "I received my pain medication 10 minutes ago, let's do my CPT now."
"I just finished eating my lunch, I'm ready for my CPT now."
The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia? pH PaO2 HCO3 PCO2
PaO2
A client undergoes a tracheostomy after many failed attempts at weaning him from a mechanical ventilator. Two days after tracheostomy, while the client is being weaned, the nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first? A. Suction the client, withdraw residual air from the cuff, and reinflate it. B. Remove the malfunctioning cuff. C.Add more air to the cuff. D. Call the physician.
Suction the client, withdraw residual air from the cuff, and reinflate it.
A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for A kink in the ventilator tubing A cut or slice in the tubing from the ventilator Malfunction of the alarm button Higher than normal endotracheal cuff pressure
A kink in the ventilator tubing
When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods? 20 to 25 seconds 0 to 5 seconds 10 to 15 seconds 30 to 35 seconds
10 to 15 seconds
A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings? 58 mm Hg 45 mm Hg 120 mm Hg 84 mm Hg
84 mm Hg
Constant bubbling in the water seal of a chest drainage system indicates which of the following problems? Tidaling Increased drainage Air leak Tension pneumothorax
Air leak
A patient is brought into the emergency department with carbon monoxide poisoning after escaping a house fire. What should the nurse monitor this patient for? Stagnant hypoxia Anemic hypoxia Histotoxic hypoxia Hypoxic hypoxia
Anemic hypoxia Anemic hypoxia is a result of decreased effective hemoglobin concentration, which causes a decrease in the oxygen-carrying capacity of the blood. It is rarely accompanied by hypoxemia. Carbon monoxide poisoning, because it reduces the oxygen-carrying capacity of hemoglobin, produces similar effects but is not strictly anemic hypoxia, because hemoglobin levels may be normal.
Which of the following is a potential complication of a low pressure in the endotracheal tube (ET) cuff?
Aspiration pneumonia
A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client? By providing a tracheostomy plug to use for verbal communication By suctioning the client frequently B y placing the call button under the client's pillow By supplying a magic slate or similar device
By supplying a magic slate or similar device
The nurse is caring for a patient with an endotracheal tube (ET). Which of the following nursing interventions is contraindicated? Deflating the cuff routinely Deflating the cuff prior to tube removal E nsuring that humidified oxygen is always introduced through the tube Checking the cuff pressure every 6 to 8 hours
Deflating the cuff routinely Routine cuff deflation is not recommended because of the increased risk for aspiration and hypoxia. The cuff is deflated before the ET is removed. Cuff pressures should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tube.
A nurse is weaning a client from mechanical ventilation. Which assessment finding indicates the weaning process should be stopped? Respiratory rate of 16 breaths/minute Runs of ventricular tachycardia Oxygen saturation of 93% Blood pressure increase from 120/74 mm Hg to 134/80 mm Hg
Runs of ventricular tachycardia Ventricular tachycardia indicates that the client isn't tolerating the weaning process. The weaning process should be stopped before lethal ventricular arrhythmias occur. A respiratory rate of 16 breaths/minute and an oxygen saturation of 93% are normal findings. Although the client's blood pressure has increased, it hasn't increased more than 20% over baseline, which would indicate that the client isn't tolerating the weaning process.
A client is prescribed postural drainage because secretions are accumulating in the upper lobes of the lungs. The nurse instructs the client to: Lay in bed with the head on a pillow. Take prescribed albuterol (Ventolin) before performing postural drainage. Perform drainage 1 hour after meals. Hold each position for 5 minutes.
Take prescribed albuterol (Ventolin) before performing postural drainage. When a client is to perform postural drainage, the nurse should instruct the client to use the prescribed bronchodilator (eg, albuterol) first. This will open airways and promote drainage. The client is to perform postural drainage before meals, not after. This will aid in preventing nausea, vomiting, and aspiration. For secretions accumulated in the upper lobes, the client will sit up or even lean forward while sitting. Head on a pillow is not a sufficient increase in height. The client is also to lay in each position for 10 to 15 minutes.
After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes? Air-leak chamber Suction control chamber Water-seal chamber Collection chamber
Water-seal chamber Fluctuations in the water-seal compartment are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respirations. The air-leak meter — not chamber — detects air leaking from the pleural space. The collection chamber connects the chest tube from the client to the system. Drainage from the tube drains into and collects in a series of calibrated columns in this chamber. The suction control chamber provides the suction, which can be controlled to provide negative pressure to the chest.
Which of the following is an adverse reaction that would require termination of the weaning process from the ventilator? PaOgreater than 60 mmHg with a FiO less than 40% Heart rate less than 100 B blood pressure increase of 20 mm Hg Vital capacity of 12 mL/kg
blood pressure increase of 20 mm Hg Criteria for termination of the weaning process includes: heart rate increase of 20 beats per minute, and systolic blood pressure increase of 20 mm Hg. A normal vital capacity is 10 to 15 mL/kg.
A nurse is caring for a client who was intubated because of respiratory failure. The client is now receiving mechanical ventilation with a preset tidal volume and number of breaths each minute. The client has the ability to breathe spontaneously between the ventilator breaths with no ventilator assistance. The nurse should document the ventilator setting as: continuous positive airway pressure (CPAP). assist-control (AC) ventilation. synchronized intermittent mandatory ventilation (SIMV). pressure support ventilation (PSV).
synchronized intermittent mandatory ventilation (SIMV).
A client has a sucking stab wound to the chest. Which action should the nurse take first? Apply a dressing over the wound and tape it on three sides. Draw blood for a hematocrit and hemoglobin level. Prepare a chest tube insertion tray. Prepare to start an I.V. line.
Apply a dressing over the wound and tape it on three sides The nurse should immediately apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line.
Which of the following is a potential complication of a low pressure in the ET cuff? Pressure necrosis Tracheal ischemia Tracheal bleeding Aspiration pneumonia
Aspiration pneumonia Low pressure in the cuff can increase the risk for aspiration pneumonia. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis.
Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain? Fluid intake for the past 24 hours Electrocardiogram (ECG) results Prior outcomes of weaning Baseline arterial blood gas (ABG) levels
Baseline arterial blood gas (ABG) levels Before weaning the client from mechanical ventilation, it's most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins.
The nurse is caring for a patient following a thoracotomy. Which of the following findings requires immediate intervention by the nurse? Heart rate: 112 bpm Moderate amounts of colorless sputum Pain of 5 on a 1 to 10 pain scale Chest tube drainage of 190 mL/hr
Chest tube drainage of 190 mL/hr
The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying? Hypoxic hypoxia Histotoxic hypoxia Anemic hypoxia Circulatory hypoxia
Circulatory hypoxia Given this patient's vital signs, he appears to be in shock. Circulatory hypoxia is hypoxia resulting from inadequate capillary circulation. It may be caused by decreased cardiac output, local vascular obstruction, low-flow states such as shock, or cardiac arrest. Although tissue partial pressure of oxygen (PO2) is reduced, arterial oxygen (PaO2) remains normal. Circulatory hypoxia is corrected by identifying and treating the underlying cause.
What treatment modality will be the most effective for this patient? Continuous positive airway pressure Surgery to remove the tonsils and adenoids Bi-level positive airway pressure Medications to assist the patient with sleep at night
Continuous positive airway pressure Continuous positive airway pressure (CPAP) provides positive pressure to the airways throughout the respiratory cycle. Although it can be used as an adjunct to mechanical ventilation with a cuffed endotracheal tube or tracheostomy tube to open the alveoli, it is also used with a leak-proof mask to keep alveoli open, thereby preventing respiratory failure. CPAP is the most effective treatment for obstructive sleep apnea because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. To use CPAP, the patient must be breathing independently.
Question 5 of 10 A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? Encouragement of coughing Use of a cooling blanket Incentive spirometry Endotracheal suctioning
Endotracheal suctioning Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.
The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique? Administer bronchodilators and mucolytic agents following the sequence. Use aerosol sprays to deodorize the client's environment after postural drainage. Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes. Perform this measure with the client once a day.
Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes.
A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm? An ET cuff leak Kinking of the ventilator tubing A disconnected ventilator tube A change in the oxygen concentration without resetting the oxygen level alarm
Kinking of the ventilator tubing
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? Partial pressure of arterial carbon dioxide (PaCO2) Bicarbonate (HCO3-) pH Partial pressure of arterial oxygen (PaO2)
Partial pressure of arterial oxygen (PaO2)
The nurse is teaching a postoperative client who had a coronary artery bypass graft about using the incentive spirometer. The nurse instructs the client to perform the exercise in the following order:
Sit in an upright position. Place the mouthpiece of the spirometer in the mouth. Breathe air in through the mouth. Hold breath for about 3 seconds. Exhale air slowly through the mouth.
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?
Suction the client's artificial airway. A high-pressure alarm on a continuous mechanical ventilator indicates an obstruction in the flow of oxygen from the machine to the client. The nurse should suction the client's artificial airway to remove respiratory secretions that could be causing the obstruction. The sounding of a ventilator alarm has no relationship to the apical pulse. Increasing the oxygen percentage and ventilating with a handheld mechanical ventilator wouldn't correct the airflow blockage.
nurse is using an in-line suction kit to suction a patient who is intubated and on a mechanical ventilator. What benefits does inline suction have for the patient? (Select all that apply.) Sustains positive end expiratory pressure (PEEP) Decreases hypoxemia Increases oxygen consumption Decreases patient anxiety Prevents aspiration
Sustains positive end expiratory pressure (PEEP) Decreases hypoxemia Decreases patient anxiety An in-line suction device allows the patient to be suctioned without being disconnected from the ventilator circuit. In-line suctioning (also called closed suctioning) decreases hypoxemia, sustains PEEP, and can decrease patient anxiety associated with suctioning (Sole et al., 2013).
The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for: Symmetry of the client's chest expansion A scheduled time for deflation of the tracheal cuff Tracheal cuff pressure set at 30 mm Hg Cool air humidified through the tube
Symmetry of the client's chest expansion
A client who must begin oxygen therapy asks the nurse why this treatment is necessary? What would the nurse identify as the goals of oxygen therapy? Select all that apply. To provide visual feedback to encourage the client to inhale slowly and deeply To provide adequate transport of oxygen in the blood To clear respiratory secretions To reduce stress on the myocardium To decrease the work of breathing
To provide adequate transport of oxygen in the blood To reduce stress on the myocardium To decrease the work of breathing
Which type of ventilator has a present volume of air to be delivered with each inspiration? Volume-controlled Pressure-cycled Negative-pressure Time-cycled
Volume-controlled With volume-controlled ventilation, the volume of air to be delivered with each inspiration is present. Negative pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a present pressure, and then cycles off, and expiration occurs passively.
The nurse is preparing to assist the health care provider with the removal of a patient's chest tube. Which of the following instructions will the nurse correctly give the patient? "Exhale forcefully while the chest tube is being removed." "When the tube is being removed, take a deep breath, exhale, and bear down." " While the chest tube is being removed, raise your arms above your head." " During the removal of the chest tube, do not move because it will make the removal more painful."
When the tube is being removed, take a deep breath, exhale, and bear down."
A nurse is caring for a client who has a tracheostomy tube and who is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by: suctioning the tracheostomy tube frequently. keeping the tracheostomy tube plugged. u sing a cuffed tracheostomy tube. using the minimal-leak technique with cuff pressure less than 25 cm H2O.
using the minimal-leak technique with cuff pressure less than 25 cm H2O.
For a client with an endotracheal (ET) tube, which nursing action is the most important? Auscultating the lungs for bilateral breath sounds Monitoring serial blood gas values every 4 hours Providing frequent oral hygiene Turning the client from side to side every 2 hours
Auscultating the lungs for bilateral breath sounds For the client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although turning the client from side to side every 2 hours, monitoring serial blood gas values every 4 hours, and providing frequent oral hygiene are appropriate actions for this client, they're secondary to ensuring adequate oxygenation.
A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs? Chest X-ray Arterial blood gas (ABG) levels Inspection Auscultation
Auscultation The nurse should assess breath sounds before doing postural drainage to determine the areas that need draining. Inspection, chest X-rays, and ABG levels are all assessment parameters that give good information about respiratory function but aren't necessary to determine lung areas requiring postural drainage.
A nurse is planning care for a client after a tracheostomy. One of the client's goals is to overcome verbal communication impairment. Which intervention should the nurse include in the care plan? Encourage the client's communication attempts by allowing him time to select or write words. Make an effort to read the client's lips to foster communication. Avoid using a tracheostomy plug because it blocks the airway. Answer questions for the client to reduce his frustration.
Encourage the client's communication attempts by allowing him time to select or write words.
A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education? Have the patient lie in a supine position during the use of the spirometer. Encourage the patient to try to stop coughing during and after using the spirometer. Encourage the patient to take approximately 10 breaths per hour, while awake. Inform the patient that using the spirometer is not necessary if the patient is experiencing pain.
Encourage the patient to take approximately 10 breaths per hour, while awake
For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan? Keeping the collection chamber at chest level Stripping the chest tube every hour Maintaining continuous bubbling in the water-seal chamber Measuring and documenting the drainage in the collection chamber
Measuring and documenting the drainage in the collection chamber The nurse should regularly measure and document the amount of chest tube drainage to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected. The nurse should keep the collection chamber below chest level to allow fluids to drain into it. The nurse shouldn't strip chest tubes because doing so may traumatize the tissue or dislodge the tube.
