Respiratory
A patient has small cell cancer of the lung. Which of the following findings requires immediate intervention by the nurse? A - Serum sodium of 118 meq/L B - Serum potassium of 5.1 meg/L C - Hematocrit of 45% D - BUN 10 mg/dl
A - Serum sodium of 118 meq/L
An alarm beeps notifying you that one of your patient's oxygen saturation is reading 89%. You arrive to the patient's room and see the patient comfortably resting in bed watching television. The A - Continue to monitor the patient B - Increase the patients oxygen to 3L C -Notify the doctor for further orders D - Turn off the alarm settings
A. Continue to monitor the patient
The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 101.4° F, a productive cough with yellow sputum and a respiratory rate of 20. Which of the following nursing diagnosis is most appropriate based upon this assessment? A. Hyperthermia related to infectious illness B. Ineffective thermoregulation related to chilling C. Ineffective breathing pattern related to pneumonia D. Ineffective airway clearance related to thick secretions
A. Hyperthermia related to infectious illness
A client experiencing a severe asthma attack has the following arterial blood gas: pH 7.33; Pco2 48; Po2 58; HCO3 26. Which of the following orders should the nurse perform first? A - Albuterol (Proventil) nebulizer. B - Chest x-ray. C - Ipratropium (Atrovent) inhaler. D - Sputum culture.
A - Albuterol (Proventil) nebulizer.
A client experiencing a severe asthma attack has the following arterial blood gas results: pH 7.33; PCO2 48 mm Hg (6.4 kPa); PO2 58 mm Hg (7.7 kPa); HCO3 26 mEq/L (26 mmol/L). Which prescription should the nurse implement first? A - Albuterol nebulizer B - Chest X-ray C - Ipratropium inhaler D - Sputum culture
A - Albuterol nebulizer
A male patient with COPD becomes dyspneic at rest. His baseline blood gas results are PaO2 70 mm Hg, PaCO2 52 mm Hg, and pH 7.34. What updated patient assessment requires the nurse's priority intervention? A - Arterial pH 7.26 B - PaCO2 50 mm Hg C -Patient in tripod position D - Increased sputum expectoration
A - Arterial pH 7.26
A nurse walks in to a client who is in respiratory distress. The client has tracheal deviation to the right side. The nurse knows to prepare for which of the following emergent procedures? A - Chest tube insertion on the left side. B - Chest tube insertion on the right side. C - Intubation D - Tracheostomy
A - Chest tube insertion on the left side.
The nurse is suctioning an intubated, mechanically ventilated patient. Complications that should be observed for include: A - Dysrhythmias B - Hyperthermia C - Hematuria D - decreased urinary output D - Decreased urinary output
A - Dysrhythmias
A previously healthy client is hospitalized with left lower lobe (LLL) bacterial pneumonia. The nurse assesses chest pain with inspiration, productive cough of thick rusty sputum, and LLL fine inspiratory crackles and low-pitched expiratory wheezing. Which of the medications that the health care provider prescribes should the nurse question? A - Furosemide 20 mg IV push every day B - Guaifenesin ER 600 mg PO every 12 hours C - Ibuprofen 600 mg PO every 6 hours PRN D - Levofloxacin 500 mg IV every day
A - Furosemide 20 mg IV push every day
Which of the following health promotion activities should the nurse include in the discharge teaching plan for a client with asthma? A - Incorporate physical exercise as tolerated into the daily routine. B - Monitor peak flow numbers after meals and at bedtime. C - Eliminate stressors in the work and home environment. D - Use sedatives to ensure uninterrupted sleep at night.
A - Incorporate physical exercise as tolerated into the daily routine.
The client with chronic obstructive pulmonary disease is taking theophylline. The nurse should instruct the client to report which signs of theophylline toxicity? Select all that apply. A - Nausea B - Vomiting C - Seizures D - Insomnia E - Vision changes
A - Nausea B - Vomiting C - Seizures D - Insomnia
The nurse is caring for a client who is mechanically ventilated, and the high-pressure ventilator alarm is sounding. The nurse understands that which complications may cause this alarm? Select all that apply. A - Water or a kink in the tube B - Biting on the ETT C - Increased secretions in the airway D - Disconnection or leak in the system E - The client ceasing spontaneous respirations.
A - Water or a kink in the tube B - Biting on the ETT C - Increased secretions in the airway
The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply. A. Activities should be resumed gradually B. Avoid contact with other individuals, except family members, for at least 6 months C. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated D. Respiratory isolation is not necessary because family members already have been exposed E. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags F. When 1 sputum culture is negative, the client is no longer considered infectious and usually can return to former employment
A. Activities should be resumed gradually C. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated D. Respiratory isolation is not necessary because family members already have been exposed E. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags
The nurse just received report on her client who is on the ventilator for volume. The nurse should be concerned if which of the following setting on the ventilator changes? A - Airway pressure increases B - Airway pressure decreases C - Any change on the vent settings is alarming D - No changes on settings, the nurse doesn't adjust the settings.
A. Airway pressure increases
The nurse is discharging a client following a status asthmaticus episode. Which information should the nurse include in the asthma-teaching plan to prevent recurrence of episodes? (Select all that apply.) A. Carrying a rapid-acting bronchodilator inhaler at all times B. Getting a yearly influenza vaccination C. Using the inhaled corticosteroid when shortness of breath occurs D. Recommending that the client not be vaccinated for pneumonia E. Avoiding breathing in strong odors and smoke
A. Carrying a rapid-acting bronchodilator inhaler at all times B. Getting a yearly influenza vaccination E. Avoiding breathing in strong odors and smoke
With acute pulmonary emboli, what do you expect to see on ABGs? A - Hypoxemia, hypercapnia, academia B - Hypoxemia, hypocapnia, alkalemia C- Hyperoxemia, hypocapnia, alkalemia D -Hyperoxemia, hypocapnia, alkalemia
B. Hypoxemia, hypocapnia, alkalemia
A client is receiving streptomycin in the treatment regimen of TB. The nurse should assess for: A - Decreased serum Creatinine B - Difficulty swallowing C - Hearing loss D - IV Infiltration
C - Hearing loss
The client is diagnosed with a pulmonary embolus and is receiving a heparin drip. The bag hanging is 20,000 units/500 mL of D5W infusing at 22 mL/hr. How many units of heparin is the client receiving each hour? A - 800 units B - 900 units C - 880 units D - 780 units
C. 880 units
The client had a right-sided chest tube inserted two (2) hours ago for a pneumothorax. Which action should the nurse take if there is no fluctuation (tidaling) in the water-seal compartment? A. Obtain an order for a stat chest x-ray. B. Increase the amount of wall suction. C. Check the tubing for kinks or clots. D. Monitor the client's pulse oximeter reading.
C. Check the tubing for kinks or clots.
Isoniazid (INH) and rifampin (Rifadin) have been prescribed for a client with TB. A nurse reviews the medical record of the client. Which of the following, if noted in the client's history, would require physician notification? A. Heart disease B. Allergy to penicillin C. Hepatitis B D. Rheumatic fever
C. Hepatitis B
A client had a Mantoux test result of an 8-mm induration. The test is considered positive when the client: a. Lives in a long-term care facility. b. Has no known risk factors c. Is immunocompromised d. Works as a healthcare provider in a hospital
C. Is immunocompromised
A 27 yr. old with asthma suffers from bronchospasm that requires him to take his albuterol inhaler 4 to 5 times per week. He takes no other medications for asthma. The nurse anticipates which change in the client's plan of care? A - Add Theophylline B - Increase the dose of his present inhaler. C - Add a cromolyn sodium inhaler. D - Add an inhaled corticosteroid.
D. Add an inhaled corticosteroid
An asthmatic patient who has a new prescription for Advair Diskus (combined fluticasone and salmeterol) asks the nurse the purpose of using two drugs. The nurse explains that a. Advair is a combination of long-acting and slow-acting bronchodilators. b. the two drugs work together to block the effects of histamine on the bronchioles. c. one drug decreases inflammation, and the other is a bronchodilator. d. the combination of two drugs works more quickly in an acute asthma attack.
c. one drug decreases inflammation, and the other is a bronchodilator.
The nurse is caring for a patient with difficulty breathing. Upon review of the patient's ABG, which results are consistent with Acute Respiratory Failure? Select all that apply. A. PaO2 - 65 mmHg B. SaO2 - 79% C. CO2 - 60 mmHg D. pH - 7.5
A. PaO2 - 65 mmHg B. SaO2 - 79% C. CO2 - 60 mmHg
A nurse is caring for a client with a temperature of 100.4° F, crackles at the right lung base, pain with deep inspiration, and dyspnea. Which of the following orders is the nurse's priority? A. Sputum specimen for culture and sensitivity B. Codeine 15 mg orally every 6 hours as needed C. Incentive spirometer every 2 hours while awake D. Amoxicillin (Amoxil) 500 mg orally 4 times a day
A. Sputum specimen for culture and sensitivity
When creating a mechanically ventilated client's plan of care for prevention of ventilator-associated pneumonia (VAP), the nurse should include which measures in the plan? Select all that apply A. Suction the oral cavity whenever needed. B. Change the ventilator circuit tubing every 2 hours. C. Maintain the client in a supine position at all times. D. Practice frequent oral hygiene, including teeth brushing. E. Wear gloves when suctioning or handling the endotracheal tube.
A. Suction the oral cavity whenever needed. D. Practice frequent oral hygiene, including teeth brushing. E. Wear gloves when suctioning or handling the endotracheal tube.
The nurse conducts a program about strategies for preventing community-acquired pneumonia at a center for senior citizens. Which statement made by a participant indicates the need for further instruction? A - "I got the flu vaccine, and it can help to prevent pneumonia." B - "I got the one-time pneumonia shot, so I won't need it again." C - "I stopped smoking a year ago, so that should help me a lot." D - "I try to avoid going to the mall during the winter months."
B - "I got the one-time pneumonia shot, so I won't need it again."
The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply. A - A low arterial PCo2 level B - A hyperinflated chest noted on the chest x-ray C - Decreased oxygen saturation with mild exercise D - A widened diaphragm noted on the chest x-ray E - Pulmonary function tests that demonstrate increased vital capacity
B - A hyperinflated chest noted on the chest x-ray C - Decreased oxygen saturation with mild exercise
A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition? A - Warm, dry skin B - Decreased wheezing C - Pulse rate of 90 beats/minute D - Respirations of 18 breaths/minute
B - Decreased wheezing
The healthcare provider is conducting teaching during a health fair about the causes of pneumonia. The healthcare provider demonstrates understanding of the causes when she states that community acquired pneumonia (CAP) can be caused by all of the following except: A - Mycoplasma B - Human papillomavirus C - Influenza D - Streptococcus pneumonia
B - Human papillomavirus
The client is scheduled to have an abdominal CT scan with IV contrast. Before the procedure, the nurse should assess the patient for: A - peptic ulcer disease B - Shellfish allergies C - Reactions to blood products D - Egg allergies
B - Shellfish allergies
The healthcare provider is preparing a patient on the medical-surgical unit for a thoracentesis. Which of the following is the most appropriate position for the patient during the procedure? A - The head of the bed flat with the patient laying on the affected side. B - Sitting up, leaning over a bedside table and feet supported on the ground or stool. C - The head of bed elevated 454545 degrees with the patient laying on the unaffected side. D - Prone, with both arms extended above the head.
B - Sitting up, leaning over a bedside table and feet supported on the ground or stool.
Your client is a 79 year old male with a history of lung cancer, COPD and diabetes mellitus, type II. He has been receiving chemotherapy and radiation therapy intermittently over the past several months. He is also being treated with oral corticosteroids to minimize episodes of dyspnea related to COPD. His chemotherapy has been placed on hold due to leukopenia. Which of the following statements best summarizes the client's current condition? A - The greatest risk to the client at this time is holding chemotherapy as planned because his cancer could get worse. B - The client is at extremely high risk for infection at this time for multiple reasons. C -The client is at risk to develop an auto-immune disease. D - An elevated WBC count in this client is indicative of active infection.
B - The client is at extremely high risk for infection at this time for multiple reasons.
The healthcare provider understands that which of the following clients is most at risk for developing pneumocystis carinii pneumonia (PCP)? A - A 45-year old man who smokes 2 packs cigarettes daily. B - A 50-year old woman with HIV. C - A 22-year old man with a history of asthma. D - A 36 -year old who works in a coal mine.
B. A 50 year old woman with HIV
A nurse is caring for a patient with ARDS. Which of the following clinical indicators would signify that this client is in respiratory failure? Select all that apply. A Pulse oximetry of 94% on room air B. A PaO2 level below 60 mmHg C. An ABG pH level of 7.35 D. A pCO2 level over 50 mmHg E. A respiratory rate of over 16/minute
B. A PaO2 level below 60 mmHg D. A pCO2 level over 50 mmHg
The healthcare provider is caring for a patient who has a pneumothorax. When assessing the patient and the chest tube drainage system, a large fibrin clot is noted in the tubing. Which additional assessment finding requires immediate action by the healthcare provider? A - Fluctuations in the water seal chamber B - A downward trend in blood pressure C - Increasing pain at the insertion site D - Decreased water in the suction control chamber
B. A downward trend in blood pressure
The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client? A - A low respiratory rate B - Diminished breath sounds C - The presence of a barrel chest D - A sucking sound at the site of injury
B. Diminished breath sounds
What do you expect to see on physical exam in a patient with a PE? A - JVD and bradycardia B - Hypoxia, tachypnea, tachycardia C - Tachypnea and bradycardia D - Tachycardia and hypotension
B. Hypoxia, tachypnea, tachycardia
Which of the following nursing interventions is of the highest priority in helping a patient expectorate thick secretions related to pneumonia? A. Humidify the oxygen as able B. Increase fluid intake to 3L/day if tolerated. C. Administer cough suppressant q4hr. D. Teach patient to splint the affected area.
B. Increase fluid intake to 3L/day if tolerated.
Twenty-four hours after having had surgery a client reports pain in the calf. What should the nurse do when the assessment reveals redness and swelling at the site of discomfort? A - Keep both legs dependent. B - Notify the health care provider. C - Apply a warm soak to the left calf. D - Administer the prescribed analgesic.
B. Notify the health care provider
A 19-year-old patient has been diagnosed with pneumonia. Upon the healthcare provider's initial assessment, she notes the patient's breathing is rapid and shallow. Place the healthcare provider's next steps in the order in which they should be performed. A - place a pulse oximeter on the patient B - listen to the patient's lung sounds C - administer oxygen via nasal cannula D - document the findings E - record the patient's respiratory rate
C A B D E
What will the nurse expect to assess in a patient with respiratory failure and hypoxemia? A - Exertional dyspnea, circumoral cyanosis, distal cyanosis B - Subcutaneous emphysema, absent breath sounds, sharp chest pain C - Agitation, disorientation, lethargy, chest pain D - Rales, distended neck veins, orthostatic hypotension
C - Agitation, disorientation, lethargy, chest pain
The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs? A - Suctioning is required frequently. B - The client's skins and mucus membranes are light pink. C - Aspiration of gastric contents occurs during suctioning. D - Excessive secretions are suctioned from the tube and stoma.
C - Aspiration of gastric contents occurs during suctioning.
The nurse knows that which of the following are risk factors for Hospital-Acquired Pneumonia? Select All That Apply A - Not getting the Pneumococcal Vaccine B - Not getting an influenza vaccine C - Elderly D - Aspiration E - Mechanical Ventilation
C - Elderly D - Aspiration E - Mechanical Ventilation
A client with pulmonary embolism may develop hypotension for which of the following reason? A - Pressure on the heart and reduced cardiac output B - Reduced blood flow to the lungs C - Increased pulmonary vascular resistance and reduced blood delivery to the left side of the heart D - Reduced blood return to the right side of the heart leading to lower blood pressure
C - Increased pulmonary vascular resistance and reduced blood delivery to the left side of the heart
As the nurse you know that acute respiratory distress syndrome (ARDS) can be caused by direct or indirect lung injury. Select below all the INDIRECT causes of ARDS: Select All That Apply A - Drowning B - Aspiration C - Sepsis D - Blood transfusion E - Pneumonia F - Pancreatitis
C - Sepsis D - Blood transfusion F - Pancreatitis
The healthcare provider is caring for four patients. Which patient should be assessed first? A - The patient who is in a tripod position and breathing through pursed lips B - The patient with a pain rating of 7 on a 0 to 10 pain scale whose oxygen saturation is 91% C - The patient with a respiratory rate of 28 and asymmetric chest wall movement D - The patient with bilateral crackles, fever, and mucopurulent sputum
C - The patient with a respiratory rate of 28 and asymmetric chest wall movement
The low tidal volume alarm on a client's ventilator keeps sounding. What is the nurse's first action? A) Manually ventilate the client. B) Put air into the endotracheal tube cuff. C) Check ventilator connections. D) Call the physician.
C) Check ventilator connections.
The low tidal volume alarm on a client's ventilator keeps sounding. What is the nurse's first action? A) Manually ventilate the client. B) Put air into the endotracheal tube cuff. C) Check ventilator connections. D) Call the physician.
C) Check ventilator connections.
The nurse evaluates that nursing interventions to promote airway clearance in a patient admitted with COPD are successful based on which of the following findings? A. Absence of dyspnea B. Improved mental status C. Effective and productive coughing D. PaO2 within normal range for the patient
C. Effective and productive coughing
The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing? A. Restricting fluids B. Placing a pillow under the knees C. Encouraging active range-of-motion exercises D. Applying a heating pad to the lower extremities
C. Encouraging active range-of-motion exercises
The client is on CPAP for weaning from a mechanical ventilator. Assessment reveals a respiratory rate of 32/min, oxygen saturation of 88 percent, and use of accessory muscles. What should the nurse anticipate will occur? A. The FiO2 will be increased. B. Weaning will continue. C. The client will be placed back on full ventilator support. D. The client will be extubated.
C. The client will be placed back on full ventilator support.
The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? A - A postoperative client preparing for discharge with a new medication B - A client requiring daily dressing changes of a recent surgical incision C - A client scheduled for a chest x-ray after insertion of a nasogastric tube D - A client with asthma who requested a breathing treatment during the previous shift
D - A client with asthma who requested a breathing treatment during the previous shift
A 34-year-old female with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/ minute, nasal flaring, and use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath sounds. Based on these findings, which action should the nurse take to initiate care of the client? A - Initiate oxygen therapy and reassess the client in 10 minutes. B - Draw blood for an arterial blood gas analysis and send the client for a chest X-ray. C - Encourage the client to relax and breathe slowly through the mouth. D - Administer bronchodilators.
D - Administer bronchodilators.
Based on the lung assessment information included in hand-off report, which client should the nurse assess first? A - Client day one postop abdominal surgery who has fine inspiratory crackles at the lung bases. B - Client with chronic bronchitis who has rhonchi in the anterior and posterior chest. C - Client with right-sided pleural effusion who has decreased breath sounds at the right base. D - Client with severe pancreatitis who has inspiratory crackles at the lung bases.
D - Client with severe pancreatitis who has inspiratory crackles at the lung bases.
The nurse receives an obese client in the PACU who underwent a procedure under general anesthesia and notes an O2 sats of 88%. Which is the most appropriate initial intervention? A - Assess pupillary response. B - Auscultate lung sounds. C - Inform anesthesia professional D - Perform head tilt and chin lift
D - Perform head tilt and chin lift
Your client has a long history of chronic obstructive pulmonary disease. You are most likely to observe: A - unequal chest expansion B - increased tactile fremitus C - atrophied neck and trapezius muscles. D - an anteroposterior to transverse chest diameter of 1:1
D - an anteroposterior to transverse chest diameter of 1:1
A client has just been intubated for placement on a mechanical ventilator. What is the first assessment of the tube placement? A) Chest X-Ray B) Auscultation of breath sounds C) Pulse oximetry reading of 95% D) End tidal CO2 monitoring
D) End tidal CO2 monitoring
After a patient with right lower-lobe pneumonia has been treated with intravenous (IV) antibiotics for 2 days, which assessment data obtained by the nurse indicates that the treatment has been effective? A) The patient coughs up small amounts of green mucus. B) Increased tactile fremitus is palpable over the right chest. C) Bronchial breath sounds are heard at the right base. D) The patient's white blood cell (WBC) count is 9000/µl.
D) The patient's white blood cell (WBC) count is 9000/µl.
You're precepting a nursing student who is assisting you care for a patient on mechanical ventilation with PEEP for treatment of ARDS. The student asks you why the PEEP setting is at 10 mmHg. Your response is: A. "This pressure setting assists the patient with breathing in and out and helps improve air flow." B. "This pressure setting will help prevent a decrease in cardiac output and hyperinflation of the lungs." C. "This pressure setting helps prevent fluid from filling the alveoli sacs." D. "This pressure setting helps open the alveoli sacs that are collapsed during exhalation."
D. "This pressure setting helps open the alveoli sacs that are collapsed during exhalation."
The patient in room 2569 calls on the call light to tell you something is wrong with his chest tube. When you arrive to the room you note that the drainage system has fallen on its side and is leaking drainage onto the floor from a crack in the system. What is your next PRIORITY? A. Place the patient in supine position and clamp the tubing. B. Notify the physician immediately. C. Disconnect the drainage system and get a new one. D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.
D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.
The client has just been diagnosed with a pulmonary embolus. Which intervention should the nurse implement? A - Administer oral anticoagulants. B - Assess the client's bowel sounds. C - Prepare the client for a thoracentesis. D - Institute and maintain bed rest.
D. Institute and maintain bed rest
The nurse should include which of the following instructions when developing a teaching plan for clients receiving INH and rifampin for treatment for TB? A. Take the medication with antacids B. Double the dosage if a drug dose is forgotten C. Increase intake of dairy products D. Limit alcohol intake
D. Limit alcohol intake
The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action? A. Exhales slowly B. Stay very still C. Inhale and exhale quickly D. Perform the Valsalva maneuver
D. Perform the Valsalva maneuver
A client with a suspected pulmonary embolus is brought to the emergency department. She complains of shortness of breath and chest pain. Which other signs and symptoms would support this diagnosis? Select All That Apply a) Low-grade fever b) Thick, green sputum c) Bradycardia d) Frothy sputum e) Tachycardia f) Blood-tinged sputum
a) Low-grade fever e) Tachycardia f) Blood-tinged sputum
When developing a discharge plan to manage the care of a client with COPD, the nurse should anticipate that the client will do which of the following? a. Develop infections easily b. Maintain current status c. Require less supplemental oxygen d. Show permanent improvement.
a. Develop infections easily
The nurse teaches a 33-year-old male patient with asthma how to administer fluticasone (Flovent HFA) by metered-dose inhaler (MDI). Which statement by the patient to the nurse indicates correct understanding of the instructions? a. "I should not use a spacer device with this inhaler." b. "I will rinse my mouth each time after I use this inhaler." c. "I will feel my breathing improve over the next 2 to 3 hours." d. "I should use this inhaler immediately if I have trouble breathing."
b. "I will rinse my mouth each time after I use this inhaler."
The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. a. Excessive bubbling in the water seal chamber B. Vigorous bubbling in the suction control chamber c. Drainage system maintained below the client's chest d. 50 mL of drainage in the drainage collection chamber e. Occlusive dressing in place over the chest tube insertion site F . Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation
c. Drainage system maintained below the client's chest d. 50 mL of drainage in the drainage collection chamber e. Occlusive dressing in place over the chest tube insertion site F . Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation
A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water seal chest tube drainage system. The nurse notes that the fluid in the water seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation? a. an obstruction is present in the chest tube b. the client is developing subcutaneous emphysema c. the chest tube system is functioning properly d. there is a leak in the chest tube system
c. the chest tube system is functioning properly
A 68-year-old male patient diagnosed with sepsis is orally intubated on mechanical ventilation. Which action is most important for the nurse to take? a. Use the open-suctioning technique. b. Administer morphine for discomfort. c. Limit noise and cluster care activities. d. Elevate the head of the bed 30 degrees.
d. Elevate the head of the bed 30 degrees.
