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The nurse is caring for a patient who has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which of the following actions should the nurse take first?
- A. Assist the patient to sit up at the bedside.
- B. Splint the patient's chest during coughing.
- C. Medicate the patient with the prescribed morphine.
- D. Have the patient use the prescribed incentive spirometer.
Correct Answer: C
Rationale: A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance but should be done after the morphine is given.
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The nurse is caring for a patient in the emergency department who has an open stab wound to the right chest. Which of the following actions should the nurse implement first?
- A. Position the patient so that the right chest is dependent.
- B. Keep the head of the patient's bed at no more than 30 degrees elevation.
- C. Tape a nonporous dressing on three sides over the chest wound.
- D. Cover the sucking chest wound firmly with an occlusive dressing.
Correct Answer: C
Rationale: The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the right side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30-45 degrees to facilitate breathing.
The nurse is caring for a patient who has just had a thoracentesis. Which of the following information is most important to communicate to the health care provider?
- A. BP is 150/90 mm Hg.
- B. Oxygen saturation is 89%.
- C. Pain level is 5/10 with a deep breath.
- D. Respiratory rate is 24 when lying flat.
Correct Answer: B
Rationale: Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 89% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low oxygen saturation is the priority.
The nurse is performing tuberculosis (TB) screening in a clinic that has many patients who have immigrated to Canada. Before doing a TB skin test on a patient, which of the following questions is most important for the nurse to ask?
- A. Is there any family history of TB?
- B. Have you received the bacille Calmette-Guérin (BCG) vaccine for TB?
- C. How long have you lived in the Canada?
- D. Do you take any over-the-counter (OTC) medications?
Correct Answer: B
Rationale: Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (such as a chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing.
The nurse is caring for a patient who is hospitalized with active tuberculosis (TB) and the nurse observes a family member who is visiting the patient. Which of the following actions by the visitor should cause the nurse to intervene?
- A. Washes hands before entering the patient's room
- B. Hands the patient a tissue from the box at the bedside
- C. Puts on a surgical face mask before visiting the patient
- D. Brings food from a 'fast-food' restaurant to the patient
Correct Answer: C
Rationale: An N95 mask, rather than a standard surgical mask, should be used when entering the patient's room because the HEPA mask can filter out 100% of small airborne particles. Handwashing before visiting the patient is not necessary, but there is no reason for the nurse to stop the family member from doing this. Because anorexia and weight loss are frequent problems in patients with TB, bringing food from outside the hospital is appropriate. The family member should wash the hands after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue.
Which of the following nursing actions is most effective in preventing aspiration pneumonia in patients who are at risk?
- A. Turn and reposition immobile patients at least every 2 hours.
- B. Place patients with altered consciousness in side-lying positions.
- C. Monitor for respiratory symptoms in patients who are immuno-suppressed.
- D. Provide for continuous subglottic aspiration in patients receiving enteral feedings.
Correct Answer: B
Rationale: The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and oxygen saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Continuous subglottic suction is recommended for intubated patients but not for all patients receiving enteral feedings.