Nokea
A patient is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching includes what?
- A. Correct use of a ventilator
- B. Correct use of incentive spirometry
- C. Correct use of a mini-nebulizer
- D. Correct technique for rhythmic breathing
Correct Answer: B
Rationale: Instruction in the use of incentive spirometry begins before surgery to familiarize the patient with its correct use. You do not teach a patient the use of a ventilator; you explain that he may be on a ventilator to help him breathe. Rhythmic breathing and mini-nebulizers are unnecessary.
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A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube?
- A. To remove air from the pleural space
- B. To drain copious sputum secretions
- C. To monitor bleeding around the lungs
- D. To assist with mechanical ventilation
Correct Answer: A
Rationale: Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. The primary purpose of a chest tube is not to drain sputum secretions, monitor bleeding, or assist with mechanical ventilation.
The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess?
- A. Fluid intake for the last 24 hours
- B. Baseline arterial blood gas (ABG) levels
- C. Prior outcomes of weaning
- D. Electrocardiogram (ECG) results
Correct Answer: B
Rationale: Before weaning a patient from mechanical ventilation, it is most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the patient is tolerating the procedure. Other assessment parameters are relevant, but less critical. Measuring fluid volume intake and output is always important when a patient is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the patients record, and the nurse can refer to them before the weaning process begins.
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient has been receiving high-flow oxygen therapy for an extended time. What symptoms should the nurse anticipate if the patient were experiencing oxygen toxicity?
- A. Bradycardia and frontal headache
- B. Dyspnea and substernal pain
- C. Peripheral cyanosis and restlessness
- D. Hypotension and tachycardia
Correct Answer: B
Rationale: Oxygen toxicity can occur when patients receive too high a concentration of oxygen for an extended period. Symptoms of oxygen toxicity include dyspnea, substernal pain, restlessness, fatigue, and progressive respiratory difficulty. Bradycardia, frontal headache, cyanosis, hypotension, and tachycardia are not symptoms of oxygen toxicity.
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.
The nurse is caring for a patient who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning the patient from a ventilator, the nurse is aware that the weaning of the patient will progress in what order?
- A. Removal from the ventilator, tube, and then oxygen
- B. Removal from oxygen, ventilator, and then tube
- C. Removal of the tube, oxygen, and then ventilator
- D. Removal from oxygen, tube, and then ventilator
Correct Answer: A
Rationale: The process of withdrawing the patient from dependence on the ventilator takes place in three stages: the patient is gradually removed from the ventilator, then from the tube, and, finally, oxygen.