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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.
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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.
Which assessments and interventions should the nurse consider when performing tracheal suctioning?
- A. Closely assessing the patient before, during, and after the procedure
- B. Hyperoxygenating the patient before and after suctioning
- C. Limiting the application of suction to 20 to 30 seconds
- D. Monitoring the pulse to detect effects of hypoxia and stimulation of the vagus nerve
- E. Using an appropriate suction pressure (80 to 150 mm Hg)
- F. Inserting the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube
Correct Answer: A,B,D,E,F
Rationale: Close assessment of the patient before, during, and after the procedure is necessary to identify complications such as hypoxia, infection, tracheal tissue damage, dysrhythmias, and atelectasis. The nurse should hyperoxygenate the patient before and after suctioning and limit the application of suction to 10 to 20 seconds. In addition, monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Using an appropriate suction pressure (80 to 150 mm Hg) will help prevent atelectasis caused by excessive negative pressure. Research suggests that insertion of the suction catheter should be limited to a predetermined length (no further than 1 cm past the length of the tracheal or endotracheal tube) to avoid tracheal mucosal damage.
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 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.
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.