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The nurse is caring for a patient who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning the patient from a ventilator, the nurse is aware that the weaning of the patient will progress in what order?
- A. Removal from the ventilator, tube, and then oxygen
- B. Removal from oxygen, ventilator, and then tube
- C. Removal of the tube, oxygen, and then ventilator
- D. Removal from oxygen, tube, and then ventilator
Correct Answer: A
Rationale: The process of withdrawing the patient from dependence on the ventilator takes place in three stages: the patient is gradually removed from the ventilator, then from the tube, and, finally, oxygen.
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The medical nurse is creating the care plan of an adult patient requiring mechanical ventilation. What nursing action is most appropriate?
- A. Keep the patient in a low Fowlers position
- B. Perform tracheostomy care at least once per day
- C. Maintain continuous bedrest
- D. Monitor cuff pressure every 8 hours
Correct Answer: D
Rationale: The cuff pressure should be monitored every 8 hours. It is important to perform tracheostomy care at least every 8 hours because of the risk of infection. The patient should be encouraged to ambulate, if possible, and a low Fowlers position is not indicated.
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.
The nurse is caring for a patient who is scheduled to have a thoracotomy. When planning preoperative teaching, what information should the nurse communicate to the patient?
- A. How to milk the chest tubing
- B. How to splint the incision when coughing
- C. How to take prophylactic antibiotics correctly
- D. How to manage the need for fluid restriction
Correct Answer: B
Rationale: Prior to thoracotomy, the nurse educates the patient about how to splint the incision with the hands, a pillow, or a folded towel. The patient is not taught how to milk the chest tubing because this is performed by the nurse. Prophylactic antibiotics are not normally used and fluid restriction is not indicated following thoracotomy.
A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube?
- A. To remove air from the pleural space
- B. To drain copious sputum secretions
- C. To monitor bleeding around the lungs
- D. To assist with mechanical ventilation
Correct Answer: A
Rationale: Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. The primary purpose of a chest tube is not to drain sputum secretions, monitor bleeding, or assist with mechanical ventilation.
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.