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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.
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A nurse is teaching a patient how to perform flow type incentive spirometry prior to his scheduled thoracic surgery. What instruction should the nurse provide to the patient?
- A. Hold the spirometer at your lips and breathe in and out like you normally would
- B. When youre ready, blow hard into the spirometer for as long as you can
- C. Take a deep breath and then blow short, forceful breaths into the spirometer
- D. Breathe in deeply through the spirometer, hold your breath briefly, and then exhale
Correct Answer: D
Rationale: The patient should be taught to place the mouthpiece of the spirometer firmly in the mouth, breathe air in through the mouth, and hold the breath at the end of inspiration for about 3 seconds. The patient should then exhale slowly through the mouthpiece.
The nurse has explained to the patient that after his thoracotomy, it will be important to adhere to a coughing schedule. The patient is concerned about being in too much pain to be able to cough. What would be an alternative nursing intervention for this client?
- A. Teach him postural drainage
- B. Teach him how to perform huffing
- C. Teach him to use a mini-nebulizer
- D. Teach him how to use a metered dose inhaler
Correct Answer: B
Rationale: The technique of huffing may be helpful for the patient with diminished expiratory flow rates or for the patient who refuses to cough because of severe pain. Huffing is the expulsion of air through an open glottis. Inhalers, nebulizers, and postural drainage are not substitutes for performing coughing exercises.
The nurse is preparing to discharge a patient after thoracotomy. The patient is going home on oxygen therapy and requires wound care. As a result, he will receive home care nursing. What should the nurse include in discharge teaching for this patient?
- A. Safe technique for self-suctioning of secretions
- B. Technique for performing postural drainage
- C. Correct and safe use of oxygen therapy equipment
- D. How to provide safe and effective tracheostomy care
Correct Answer: C
Rationale: Respiratory care and other treatment modalities (oxygen, incentive spirometry, chest physiotherapy [CPT], and oral, inhaled, or IV medications) may be continued at home. Therefore, the nurse needs to instruct the patient and family in their correct and safe use. The scenario does not indicate the patient needs help with suctioning, postural drainage, or tracheostomy care.
The home care nurse is assessing a patient who requires home oxygen therapy. What criterion indicates that an oxygen concentrator will best meet the needs of the patient in the home environment?
- A. The patient desires a low-maintenance oxygen delivery system that delivers oxygen flow rates up to 6 L/min
- B. The patient requires a high-flow system for use with a tracheostomy collar
- C. The patient desires a portable oxygen delivery system that can deliver 2 L/min
- D. The patient's respiratory status requires a system that provides an FiO2 of 65%
Correct Answer: C
Rationale: The use of oxygen concentrators is another means of providing varying amounts of oxygen, especially in the home setting. They can deliver oxygen flows from 1 to 10 L/min and provide an FiO2 of about 40%. They require regular maintenance and are not used for high-flow applications. The patient desiring a portable oxygen delivery system of 2 L/min will benefit from the use of an oxygen concentrator.
A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this patient is necessary. What is the main rationale for this?
- A. Maintaining a patent airway
- B. Preventing the need for suctioning
- C. Maintaining the sterility of the patients airway
- D. Increasing the patients lung compliance
Correct Answer: A
Rationale: Maintaining a patent (open) airway is achieved through meticulous airway management, whether in an emergency situation such as airway obstruction or in long-term management, as in caring for a patient with an endotracheal or a tracheostomy tube. The other answers are incorrect.