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The home care nurse is visiting a patient newly discharged home after a lobectomy. What would be most important for the home care nurse to assess?
- A. Resumption of the patients ADLs
- B. The familys willingness to care for the patient
- C. Nutritional status and fluid balance
- D. Signs and symptoms of respiratory complications
Correct Answer: D
Rationale: The nurse assesses the patients adherence to the postoperative treatment plan and identifies acute or late postoperative complications. All options presented need assessment, but respiratory complications are the highest priority because they affect the patients airway and breathing.
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The nurse is caring for a patient who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. What method of oxygen delivery is most appropriate for the patients needs?
- A. Non-rebreathing mask
- B. Nasal cannula
- C. Simple mask
- D. Partial-rebreathing mask
Correct Answer: B
Rationale: A nasal cannula is used when the patient requires a low to medium concentration of oxygen for which precise accuracy is not essential. The Venturi mask is used primarily for patients with COPD because it can accurately provide an appropriate level of supplemental oxygen, thus avoiding the risk of suppressing the hypoxic drive. The patients respiratory status does not require a partial- or non-rebreathing mask.
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.
The nurse has admitted a patient who is scheduled for a thoracic resection. The nurse is providing preoperative teaching and is discussing several diagnostic studies that will be required prior to surgery. Which study will be performed to determine whether the planned resection will leave sufficient functioning lung tissue?
- A. Pulmonary function studies
- B. Exercise tolerance tests
- C. Arterial blood gas values
- D. Chest x-ray
Correct Answer: A
Rationale: Pulmonary function studies are performed to determine whether the planned resection will leave sufficient functioning lung tissue. ABG values are assessed to provide a more complete picture of the functional capacity of the lung. Exercise tolerance tests are useful to determine if the patient who is a candidate for pneumonectomy can tolerate removal of one of the lungs. Preoperative studies, such as a chest x-ray, are performed to provide a baseline for comparison during the postoperative period and to detect any unsuspected abnormalities.
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 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.