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A nurse has performed tracheal suctioning on a patient who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention?
- A. Determine whether the patient can now perform forced expiratory technique (FET)
- B. Percuss the patients lungs and thorax
- C. Measure the patients oxygen saturation
- D. Have the patient perform incentive spirometry
Correct Answer: C
Rationale: The patients response to suctioning is usually determined by performing chest auscultation and by measuring the patients oxygen saturation. FET, incentive spirometry, and percussion are not normally used as evaluative techniques.
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Postural drainage has been ordered for a patient who is having difficulty mobilizing her bronchial secretions. Before repositioning the patient and beginning treatment, the nurse should perform what health assessment?
- A. Chest auscultation
- B. Pulmonary function testing
- C. Chest percussion
- D. Thoracic palpation
Correct Answer: A
Rationale: Chest auscultation should be performed before and after postural drainage in order to evaluate the effectiveness of the therapy. Percussion and palpation are less likely to provide clinically meaningful data for the nurse. PFTs are normally beyond the scope of the nurse and are not necessary immediately before postural drainage.
The nurse is discussing activity management with a patient who is postoperative following thoracotomy. What instructions should the nurse give to the patient regarding activity immediately following discharge?
- A. Walk 1 mile 3 to 4 times a week
- B. Use weights daily to increase arm strength
- C. Walk on a treadmill 30 minutes daily
- D. Perform shoulder exercises five times daily
Correct Answer: D
Rationale: The nurse emphasizes the importance of progressively increased activity. The nurse also instructs the patient on the importance of performing shoulder exercises five times daily. The patient should ambulate with limits and realize that the return of strength will likely be gradual and likely will not include weight lifting or lengthy walks.
While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of the patients closed chest-drainage system. What should the nurse conclude?
- A. The system is functioning normally
- B. The patient has a pneumothorax
- C. The system has an air leak
- D. The chest tube is obstructed
Correct Answer: C
Rationale: Constant bubbling in the chamber often indicates an air leak and requires immediate assessment and intervention. The patient with a pneumothorax will have intermittent bubbling in the water-seal chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.
The nurse caring for a patient with an endotracheal tube recognizes several disadvantages of an endotracheal tube. What would the nurse recognize as a disadvantage of endotracheal tubes?
- A. Cognition is decreased
- B. Daily arterial blood gases (ABGs) are necessary
- C. Slight tracheal bleeding is anticipated
- D. The cough reflex is depressed
Correct Answer: D
Rationale: There are several disadvantages of an endotracheal tube. Disadvantages include suppression of the patients cough reflex, thickening of secretions, and depressed swallowing reflexes. Ulceration and stricture of the larynx or trachea may develop, but bleeding is not an expected finding. The tube should not influence cognition and daily ABGs are not always required.
A patients plan of care specifies postural drainage. What action should the nurse perform when providing this noninvasive therapy?
- A. Administer the treatment with the patient in a high Fowlers or semi-Fowlers position
- B. Perform the procedure immediately following the patients meals
- C. Apply percussion firmly to bare skin to facilitate drainage
- D. Assist the patient into a position that will allow gravity to move secretions
Correct Answer: D
Rationale: Postural drainage is usually performed two to four times per day. The patient uses gravity to facilitate postural draining. The skin should be covered with a cloth or a towel during percussion to protect the skin. Postural drainage is not administered in an upright position or directly following a meal.