Nokea
A nurse educator is reviewing the indications for chest drainage systems with a group of medical nurses. What indications should the nurses identify? Select all that apply.
- A. Post thoracotomy
- B. Spontaneous pneumothorax
- C. Need for postural drainage
- D. Chest trauma resulting in pneumothorax
- E. Pleurisy
Correct Answer: A,B,D
Rationale: Chest drainage systems are used in treatment of spontaneous pneumothorax and trauma resulting in pneumothorax. Postural drainage and pleurisy are not criteria for use of a chest drainage system.
You may also like to solve these questions
The medical nurse is creating the care plan of an adult patient requiring mechanical ventilation. What nursing action is most appropriate?
- A. Keep the patient in a low Fowlers position
- B. Perform tracheostomy care at least once per day
- C. Maintain continuous bedrest
- D. Monitor cuff pressure every 8 hours
Correct Answer: D
Rationale: The cuff pressure should be monitored every 8 hours. It is important to perform tracheostomy care at least every 8 hours because of the risk of infection. The patient should be encouraged to ambulate, if possible, and a low Fowlers position is not indicated.
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 patients discharge teaching?
- A. How to count her respirations accurately
- B. How to collect serial sputum samples
- C. How to independently wean herself from treatment
- D. How to perform diaphragmatic breathing
Correct Answer: D
Rationale: Diaphragmatic breathing is a helpful technique to prepare for proper use of the small-volume nebulizer. Patient teaching would not include counting respirations and the patient should not wean herself from treatment without the involvement of her primary care provider. Serial sputum samples are not normally necessary.
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 the water seal rises and falls in rhythm with the patients respirations. How should the nurse best respond to this assessment finding?
- A. Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes
- B. Inform the physician promptly that there is in imminent leak in the drainage system
- C. Encourage the patient to do deep breathing and coughing exercises
- D. Document that the chest drainage system is operating as it is intended
Correct Answer: D
Rationale: Fluctuation of the water level in the water seal shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent. No further action is needed.
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 patients needs?
- A. Non-rebreathing mask
- B. Nasal cannula
- C. Simple mask
- D. Partial-rebreathing mask
Correct Answer: B
Rationale: A nasal cannula is used when the patient requires a low to medium concentration of oxygen for which precise accuracy is not essential. The Venturi mask is used primarily for patients with COPD because it can accurately provide an appropriate level of supplemental oxygen, thus avoiding the risk of suppressing the hypoxic drive. The patients respiratory status does not require a partial- or non-rebreathing mask.
A nurse is teaching a patient how to perform flow type incentive spirometry prior to his scheduled thoracic surgery. What instruction should the nurse provide to the patient?
- A. Hold the spirometer at your lips and breathe in and out like you normally would
- B. When youre ready, blow hard into the spirometer for as long as you can
- C. Take a deep breath and then blow short, forceful breaths into the spirometer
- D. Breathe in deeply through the spirometer, hold your breath briefly, and then exhale
Correct Answer: D
Rationale: The patient should be taught to place the mouthpiece of the spirometer firmly in the mouth, breathe air in through the mouth, and hold the breath at the end of inspiration for about 3 seconds. The patient should then exhale slowly through the mouthpiece.