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The nurse caring for a patient with an endotracheal tube recognizes several disadvantages of an endotracheal tube. What would the nurse recognize as a disadvantage of endotracheal tubes?
- A. Cognition is decreased
- B. Daily arterial blood gases (ABGs) are necessary
- C. Slight tracheal bleeding is anticipated
- D. The cough reflex is depressed
Correct Answer: D
Rationale: There are several disadvantages of an endotracheal tube. Disadvantages include suppression of the patients cough reflex, thickening of secretions, and depressed swallowing reflexes. Ulceration and stricture of the larynx or trachea may develop, but bleeding is not an expected finding. The tube should not influence cognition and daily ABGs are not always required.
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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.
A patient recovering from thoracic surgery is on long-term mechanical ventilation and becomes very frustrated when he tries to communicate. What intervention should the nurse perform to assist the patient?
- A. Assure the patient that everything will be all right and that remaining calm is the best strategy
- B. Ask a family member to interpret what the patient is trying to communicate
- C. Ask the physician to wean the patient off the mechanical ventilator to allow the patient to speak freely
- D. Express empathy and then encourage the patient to write, use a picture board, or spell words with an alphabet board
Correct Answer: D
Rationale: If the patient uses an alternative method of communication, he will feel in better control and likely be less frustrated. Assuring the patient that everything will be all right offers false reassurance, and telling him not to be upset minimizes his feelings. Neither of these methods helps the patient to communicate. In a patient with an endotracheal or tracheostomy tube, the family members are also likely to encounter difficulty interpreting the patients wishes. Making them responsible for interpreting the patients gestures may frustrate the family. The patient may be weaned off a mechanical ventilator only when the physiologic parameters for weaning have been met.
The OR nurse is setting up a water-seal chest drainage system for a patient who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system?
- A. 20 cm H2O
- B. 15 cm H2O
- C. 10 cm H2O
- D. 5 cm H2O
Correct Answer: A
Rationale: The amount of suction is determined by the water level. It is usually set at 20 cm H2O; adding more fluid results in more suction.
The physician has ordered continuous positive airway pressure (CPAP) with the delivery of a patients high-flow oxygen therapy. The patient asks the nurse what the benefit of CPAP is. What would be the nurses best response?
- A. CPAP allows a higher percentage of oxygen to be safely used
- B. CPAP allows a lower percentage of oxygen to be used with a similar effect
- C. CPAP allows for greater humidification of the oxygen that is administered
- D. CPAP allows for the elimination of bacterial growth in oxygen delivery systems
Correct Answer: B
Rationale: Prevention of oxygen toxicity is achieved by using oxygen only as prescribed. Often, positive end-expiratory pressure (PEEP) or CPAP is used with oxygen therapy to reverse or prevent microatelectasis, thus allowing a lower percentage of oxygen to be used. Oxygen is moistened by passing through a humidification system. Changing the tubing on the oxygen therapy equipment is the best technique for controlling bacterial growth.
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.