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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.
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A nurse in the emergency department is caring for a patient who was brought in by fire rescue due to a heroin overdose. The nurse notes the patient is not breathing. What action will the nurse take immediately?
- A. Tilt the patient's head forward.
- B. Begin ventilation using a manual resuscitation bag (Ambu bag).
- C. Place the mask tightly over the patient's nose and mouth.
- D. Pull the patient's jaw backward.
- E. Compress the bag twice the normal respiratory rate for the patient.
- F. Recommend that a sputum culture for cytology is obtained.
Correct Answer: B,C
Rationale: The priority is to establish ventilation using the manual resuscitation bag to provide emergency or rescue breathing. The nurse tilts the head back, pulls the jaw forward, and positions the mask tightly over the patient's nose and mouth. The bag is compressed at a rate that approximates normal respiratory rate (e.g., 12 to 20 breaths/min in adults). Sputum for cytology is done primarily to detect cells that may be malignant, determine organisms causing infection, and identify blood or pus in the sputum. Note that the bag, with the mask removed, also fits easily over tracheostomy and endotracheal tubes.
A nurse plans to suction a patient's endotracheal tube using the open suction technique. Which intervention is appropriate for this technique?
- A. Using a suction catheter that is the diameter of the endotracheal tube
- B. Maintaining the patient in the supine position
- C. Administering oxygen prior to suctioning
- D. Changing the inline suction device every 24 hours
Correct Answer: C
Rationale: To prevent hypoxemia, prior to endotracheal suctioning, the nurse provides 100% oxygen for a minimum of 30 seconds. This is referred to as hyperoxygenation. The nurse limits the application of suction to no more than 10 to 15 seconds. The external diameter of the suction catheter should not exceed half of the internal diameter of the endotracheal tube. An inline suction device is considered a closed, self-contained system used for a 'closed technique' for suction; these are changed every 24 hours.
A nurse is assessing a patient with COPD who is experiencing dyspnea. What action will the nurse take first?
- A. Place the patient in Fowler position.
- B. Encourage diaphragmatic breathing.
- C. Ask the patient to cough.
- D. Initiate oral suctioning of secretions.
Correct Answer: A
Rationale: Patients with COPD experience dyspnea related to problems with ventilation and/or hypoxemia. One of the most common symptoms of hypoxia is dyspnea (difficulty breathing). Elevating the head of the bed will improve respiratory expansion and oxygenation. Coughing to facilitate secretion removal, pursed-lip breathing, and/or diaphragmatic breathing may be indicated, after sitting the patient up. Suction is indicated for patients demonstrating the presence of secretions, such as adventitious breath sounds or moist cough with phlegm; there is no indication this patient requires suctioning at this time.
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 student with a history of asthma visits the school nurse reporting difficulty breathing and wheezing. Which tool would the nurse use to assess the severity of airway resistance?
- A. Peak flow meter
- B. End-tidal CO2 monitor
- C. Chest tube
- D. Arterial blood gas
Correct Answer: A
Rationale: A peak flow meter is used to assess the point of highest flow during forced expiration. It is routinely used by and for patients with moderate or severe asthma to measure the severity of the disease and degree of disease management. Capnography or end-tidal CO2 monitoring is used for assessing and monitoring ventilation and placement of artificial airways, predicting patients who are at risk for respiratory compromise, are experiencing partial or complete airway obstruction, or are experiencing hypoventilation. A chest tube is used to remove air or fluid from the pleural space. The arterial blood gas (ABG) is used to assess oxygenation, ventilation, and acid-base status; it is invasive and not performed in the school setting.