Nokea
A patient with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the physician to order?
- A. Non-rebreather air mask
- B. Tracheostomy collar
- C. Venturi mask
- D. Face tent
Correct Answer: C
Rationale: The Venturi mask provides the most accurate method of oxygen delivery. Other methods of oxygen delivery include the aerosol mask, tracheostomy collar, and face tents, but these do not match the precision of a Venturi mask.
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A patient has been discharged home after thoracic surgery. The home care nurse performs the initial visit and finds the patient discouraged and saddened. The client states, I am recovering so slowly. I really thought I would be better by now. What nursing action should the nurse prioritize?
- A. Provide emotional support to the patient and family
- B. Schedule a visit to the patients primary physician within 24 hours
- C. Notify the physician that the patient needs a referral to a psychiatrist
- D. Place a referral for a social worker to visit the patient
Correct Answer: A
Rationale: The recovery process may take longer than the patient had expected, and providing support to the patient is an important task for the home care nurse. It is not necessary, based on this scenario, to schedule a visit with the physician within 24 hours, or to get a referral to a psychiatrist or a social worker.
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.
The nurse is preparing to suction a patient with an endotracheal tube. What should be the nurses first step in the suctioning process?
- A. Explain the suctioning procedure to the patient and reposition the patient
- B. Turn on suction source at a pressure not exceeding 120 mm Hg
- C. Assess the patients lung sounds and SAO2 via pulse oximeter
- D. Perform hand hygiene and don nonsterile gloves, goggles, gown, and mask
Correct Answer: C
Rationale: Assessment data indicate the need for suctioning and allow the nurse to monitor the effect of suction on the patients level of oxygenation. Explaining the procedure would be the second step; performing hand hygiene is the third step, and turning on the suction source is the fourth step.
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.