Nokea
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.
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The nurse is performing nasotracheal suctioning on a medical patient and obtains copious amounts of secretions from the patients airway, even after inserting and withdrawing the catheter several times. How should the nurse proceed?
- A. Continue suctioning the patient until no more secretions are obtained
- B. Perform chest physiotherapy rather than nasotracheal suctioning
- C. Wait several minutes and then repeat suctioning
- D. Perform postural drainage and then repeat suctioning
Correct Answer: C
Rationale: If additional suctioning is needed, the nurse should withdraw the catheter to the back of the pharynx, reassure the patient, and oxygenate for several minutes before resuming suctioning. Chest physiotherapy and postural drainage are not necessarily indicated.
What would the critical care nurse recognize as a condition that may indicate a patients need to have a tracheostomy?
- A. A patient has a respiratory rate of 10 breaths per minute
- B. A patient requires permanent ventilation
- C. A patient exhibits symptoms of dyspnea
- D. A patient has respiratory acidosis
Correct Answer: B
Rationale: A tracheostomy permits long-term use of mechanical ventilation to prevent aspiration of oral and gastric secretions in the unconscious or paralyzed patient. Indications for a tracheostomy do not include a respiratory rate of 10 breaths per minute, symptoms of dyspnea, or respiratory acidosis.
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.
A nurse educator is reviewing the indications for chest drainage systems with a group of medical nurses. What indications should the nurses identify? Select all that apply.
- A. Post thoracotomy
- B. Spontaneous pneumothorax
- C. Need for postural drainage
- D. Chest trauma resulting in pneumothorax
- E. Pleurisy
Correct Answer: A,B,D
Rationale: Chest drainage systems are used in treatment of spontaneous pneumothorax and trauma resulting in pneumothorax. Postural drainage and pleurisy are not criteria for use of a chest drainage system.
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.