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A nurse is caring for a patient who has a pleural chest tube attached to a disposable chest drainage system. Which nursing actions are indicated for this patient?
- A. Avoiding turning the patient to prevent disconnections in the tubing
- B. Maintaining an occlusive dressing on the site
- C. Assessing the patient for signs of respiratory distress
- D. Keeping the chest drainage device at the level of the patient's thorax
- E. Ensuring there are no dependent loops or kinks in the tubing
- F. Observing for bubbles indicating air leak in the water seal chamber
Correct Answer: B,C,E,F
Rationale: The chest drainage collection device must be positioned below the tube's insertion site. Maintaining an occlusive dressing helps prevent air leak; assess for crepitus around the chest tube site indicating air leak. Avoid dependent loops or kinks in the tubing, which could impede drainage. Assess for bubbling in the water seal, maintaining the water level at the 2-cm mark. When a chest tube becomes separated from the drainage device, the nurse should submerge the tube's end in water, creating a temporary water seal and allowing air to escape until a new drainage unit can be attached.
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A nurse in the PACU is performing oral suctioning for a patient with an oropharyngeal airway, when the patient begins to vomit. What is the nurse's priority nursing action at this time?
- A. Removing the suction catheter and elevating the head of the bed
- B. Notifying the primary health care provider
- C. Confirming the size of the oral airway is correct
- D. Placing the patient in the supine position
Correct Answer: A
Rationale: The nurse discontinues suctioning, elevates the head of the bed, and turns the patient to the side to prevent aspiration. Airway protection takes priority; after positioning the patient, the nurse continues to suction the airway and oropharynx. Once airway patency has been established, the nurse will notify the provider of vomiting. There is no indication the oral airway is too large. Placing the patient supine while vomiting is inappropriate, as that could promote aspiration.
A patient with COPD is unable to perform personal hygiene without becoming exhausted. What nursing intervention would be appropriate for this patient?
- A. Assisting with all bathing and hygiene
- B. Telling the patient to avoid speaking during hygiene
- C. Teaching the patient to take short shallow breaths during activity
- D. Taking rest periods between activities
Correct Answer: D
Rationale: To prevent fatigue during activities including hygiene, the nurse should group (personal care) activities into smaller steps and encourage rest periods between activities. The nurse promotes and maintains dignity, independence, and strength by assisting with activities when the patient has difficulty. The nurse should encourage the patient to voice feelings and concerns about self-care deficits and teach the patient to coordinate pursed-lip or diaphragmatic breathing with the activity.
A nurse is monitoring a patient with a pleural effusion after a thoracentesis removing 1,400 mL of dark yellow liquid. What is the expected outcome of this procedure?
- A. Tachycardia
- B. Hypotension
- C. Reduced dyspnea
- D. Pulse oximetry of 88%
Correct Answer: C
Rationale: Thoracentesis involves inserting a needle into the pleural space to aspirate pleural fluid, air, or both. A thoracentesis may be performed to obtain a specimen for diagnostic purposes, to remove fluid or air that has accumulated in the pleural cavity and is causing respiratory difficulty and discomfort, or to instill medications.
A nurse is providing teaching for a patient who will undergo cardiac surgery and return to the intensive care unit with an endotracheal tube. What education is most important for the nurse to provide?
- A. The endotracheal tube will drain out excess secretions from the surgical site.
- B. This tube is used to facilitate breathing; you will not be able to speak while it is in place.
- C. This is a surgically placed tube in your neck; we will suction it frequently to remove mucus.
- D. Your oxygenation will be monitored frequently using pulse oximetry.
Correct Answer: B
Rationale: Patients with an endotracheal tube are unable to speak. Explaining this to the patient preoperatively, along with information that they will be closely monitored, can help decrease anxiety. The endotracheal tube is used during anesthesia or for mechanical ventilation; it is not a surgical drain. A tracheostomy, located in the neck area, is a surgically placed artificial airway. While pulse oximetry will be used to monitor oxygenation, to prevent undue anxiety, it is most important that the patient understands speech will not be possible.
A nurse is planning to suction a patient's tracheostomy tube the day after its placement. Which action by the nurse is absolutely essential?
- A. Assessing the need to premedicate with an analgesic
- B. Placing the patient in low Fowler position
- C. Inserting the obturator into the outer cannula
- D. Maintaining aseptic technique
Correct Answer: D
Rationale: Sterile technique is used for tracheal suctioning, to reduce the risk of introduction of disease-causing organisms. Aseptic technique is imperative to avoid introducing organisms into the lower airway. An obturator, which guides the direction of the outer cannula, is inserted into the tube during placement and removed once the outer cannula of the tube is in place. In the home setting, clean technique is used.