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After undergoing a left pneumonectomy, a female patient has a chest tube in place for drainage. When caring for this patient, the nurse must:
- A. Monitor fluctuations in the water-seal chamber.
- B. Clamp the chest tube once every shift.
- C. Encourage coughing and deep breathing.
- D. Milk the chest tube every 2 hours.
Correct Answer: C
Rationale: Step-by-step rationale for why "Encourage coughing and deep breathing" (Choice C) is the correct answer:
1. After pneumonectomy, patient is at risk for lung complications.
2. Encouraging coughing and deep breathing helps prevent atelectasis and pneumonia.
3. It promotes lung expansion and clears secretions.
4. This intervention supports respiratory function and aids in recovery.
Summary of why the other choices are incorrect:
A. Monitoring fluctuations in the water-seal chamber (Choice A) is important for assessing the status of the chest tube drainage, but not the immediate priority for patient care post-pneumonectomy.
B. Clamping the chest tube once every shift (Choice B) is not recommended as it can lead to complications like tension pneumothorax.
D. Milking the chest tube every 2 hours (Choice D) is unnecessary and can cause trauma to the lung tissue and increase the risk of infection.
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Rate and depth of respiration shall increase when
- A. Oxygen concentration increases
- B. CO2 concentration increases
- C. Bicarbonate concentration increases
- D. Bicarbonate concentration decrease
Correct Answer: B
Rationale: The correct answer is B: CO2 concentration increases. When CO2 levels rise in the blood, it leads to an increase in the acidity of the blood, triggering the respiratory centers in the brain to increase the rate and depth of respiration in order to expel excess CO2 and restore the pH balance.
Explanation for other choices:
A: Oxygen concentration increases - An increase in oxygen concentration does not directly stimulate an increase in respiration rate or depth. The respiratory drive is primarily regulated by CO2 levels.
C: Bicarbonate concentration increases - While bicarbonate is involved in the acid-base balance in the body, it does not directly influence the rate and depth of respiration.
D: Bicarbonate concentration decreases - A decrease in bicarbonate concentration may affect acid-base balance, but it does not have a direct effect on respiratory rate and depth.
A 19-year-old client comes to the emergency department with acute asthma. His respiratory rate is 44 breaths/minute, and he appears in acute respiratory distress. Which of the following actions should be taken first?
- A. Take a full medical history.
- B. Give a bronchodilator by nebulizer.
- C. Apply a cardiac monitor to the client.
- D. Provide emotional support to the client.
Correct Answer: B
Rationale: The correct answer is B: Give a bronchodilator by nebulizer. In acute asthma, the priority is to relieve respiratory distress by opening up the airways. Bronchodilators help to quickly alleviate bronchospasm and improve airflow. This action should be taken first to improve the client's breathing. Taking a full medical history (A) can be important but is not the priority in this acute situation. Applying a cardiac monitor (C) is not the immediate concern in acute asthma. Providing emotional support (D) is also important but should come after ensuring the client's respiratory distress is managed.
A nurse is assessing a client who is recovering from a lung biopsy. The client's breath sounds are absent. While another nurse calls the Rapid Response Team
- A. what action by the nurse takes is most important?
- B. Take a full set of vital signs.
- C. Obtain pulse oximetry reading.
- D. Ask the patient about hemoptysis.
Correct Answer: B
Rationale: The correct answer is B, taking a full set of vital signs, as it is crucial in assessing the client's overall condition and detecting any signs of deterioration. Vital signs include blood pressure, heart rate, respiratory rate, and temperature, which provide valuable information about the client's cardiovascular and respiratory status. In this scenario, absent breath sounds indicate potential respiratory compromise, making it essential to monitor vital signs for any signs of respiratory distress or instability.
Choice A is incorrect because calling the Rapid Response Team is important, but assessing the client's vital signs should take priority to provide immediate information on the client's condition. Choice C, obtaining pulse oximetry reading, is also important but may not provide a comprehensive assessment of the client's overall condition compared to a full set of vital signs. Choice D, asking about hemoptysis, is not the most urgent action to take in this situation as assessing vital signs would provide more immediate and critical information for the client's management.
A charge nurse is rounding on several older clients on ventilators in the Intensive Care Unit whom the nurse identifies as being at high risk for ventilator-associated pneumonia. To reduce this risk what activity would the nurse delegate to the assistive personnel (AP)?
- A. Encourage between-meal snacks.
- B. Monitor temperature every 4 hours.
- C. Provide oral care every 4 hours.
- D. Report any new onset of cough.
Correct Answer: C
Rationale: The correct answer is C: Provide oral care every 4 hours. Oral care helps prevent ventilator-associated pneumonia by reducing the risk of oral bacteria being aspirated into the lungs. The AP can assist with oral care under the nurse's supervision.
A: Encouraging between-meal snacks does not directly address pneumonia risk.
B: Monitoring temperature is important but not specific to ventilator-associated pneumonia prevention.
D: Reporting new cough onset is important but does not directly reduce the risk of ventilator-associated pneumonia.
The nurse is caring for a 30-year-old American Indian female who is taking Rifater, a drug
containing rifampin, isoniazid, and pyrazinamide. The patient asks how long she will have to
take the medication. Which response explains when the patient may discontinue the
medication?
- A. When the sputum culture comes back negative.
- B. When the medication has been taken for 9 months
- C. When three consecutive sputum cultures are negative
- D. When the tuberculin skin test (TST) is no longer positive
Correct Answer: C
Rationale: The correct answer is C: When three consecutive sputum cultures are negative. This indicates successful treatment completion and eradication of the tuberculosis infection. A negative sputum culture confirms that the patient is no longer infectious and can safely discontinue the medication.
Choice A is incorrect because a single negative sputum culture does not guarantee complete eradication of the infection. Choice B is incorrect as the standard treatment duration for tuberculosis is typically 6-9 months, but discontinuation should be based on sputum culture results. Choice D is incorrect as the TST can remain positive even after successful treatment, as it reflects exposure to the tuberculosis bacteria, not active infection status.