Nokea
The nurse is caring for a patient with bacterial pneumonia who has pleurisy. Which of the following actions should the nurse implement to promote airway clearance?
- A. Assist the patient to splint the chest when coughing.
- B. Educate the patient about the need for fluid restrictions.
- C. Encourage the patient to wear the nasal oxygen cannula.
- D. Instruct the patient on the pursed lip breathing technique.
Correct Answer: A
Rationale: Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal oxygen will improve gas exchange, but will not improve airway clearance. Pursed lip breathing is used to improve gas exchange in patients with COPD, but will not improve airway clearance.
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A patient with newly diagnosed lung cancer tells the nurse, 'I think I am going to die pretty soon.' Which of the following responses by the nurse is best?
- A. Would you like to talk to the hospital chaplain about your feelings?
- B. Can you tell me what it is that makes you think you will die so soon?
- C. Are you afraid that the treatment for your cancer will not be effective?
- D. Do you think that taking an antidepressant medication would be helpful?
Correct Answer: B
Rationale: The nurse's initial response should be to collect more assessment data about the patient's statement. The answer beginning 'Can you tell me what it is' is the most open-ended question and will offer the best opportunity for obtaining more data. The answer beginning, 'Are you afraid' implies that the patient thinks that the cancer will be immediately fatal, although the patient's statement may not be related to the cancer diagnosis. The remaining two answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.
The nurse is caring for a patient who has a right-sided chest tube following a thoracotomy and has continuous bubbling in the suction-control chamber of the collection device. Which of the following actions should the nurse implement?
- A. Document the presence of a large air leak.
- B. Obtain and attach a new collection device.
- C. Notify the surgeon of a possible pneumothorax.
- D. Take no further action with the collection device.
Correct Answer: D
Rationale: Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. A new collection device is needed when the collection chamber is filled.
The nurse is caring for a patient who had a thoracotomy 1 hour ago and reports incisional pain at a level 7 out of 10 and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which of the following actions is best for the nurse to take next?
- A. Administer the prescribed PRN morphine.
- B. Assist the patient to deep breathe and cough.
- C. Milk the chest tube gently to remove any clots.
- D. Tape the area around the insertion site of the chest tube.
Correct Answer: A
Rationale: The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy and would not require milking of the chest tube. An air leak is expected in the initial postoperative period after thoracotomy.
The health care provider inserts a chest tube in a patient with a hemo-pneumothorax. When monitoring the patient after the chest tube placement, which of the following findings is of greatest concern?
- A. A large air leak in the water-seal chamber
- B. 400 mL of blood in the collection chamber
- C. Complaint of pain with each deep inspiration
- D. Subcutaneous emphysema at the insertion site
Correct Answer: B
Rationale: The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. Drainage greater than 100 mL is to be reported to the health care provider. A large air leak would be expected immediately after chest tube placement for pneumothorax. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax.
The nurse is caring for a patient with a pleural effusion who is scheduled for a thoracentesis. Which of the following actions should the nurse implement prior to the procedure?
- A. Start a peripheral intravenous line to administer the necessary sedative drugs.
- B. Position the patient sitting upright on the edge of the bed and leaning forward.
- C. Remove the water pitcher and remind the patient not to eat or drink anything for 6 hours.
- D. Instruct the patient about the importance of incentive spirometer use after the procedure.
Correct Answer: B
Rationale: When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The lung will expand after the effusion is removed. Incentive spirometry is not needed to assure alveolar expansion. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious.