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The nurse is discussing activity management with a patient who is postoperative following thoracotomy. What instructions should the nurse give to the patient regarding activity immediately following discharge?
- A. Walk 1 mile 3 to 4 times a week
- B. Use weights daily to increase arm strength
- C. Walk on a treadmill 30 minutes daily
- D. Perform shoulder exercises five times daily
Correct Answer: D
Rationale: The nurse emphasizes the importance of progressively increased activity. The nurse also instructs the patient on the importance of performing shoulder exercises five times daily. The patient should ambulate with limits and realize that the return of strength will likely be gradual and likely will not include weight lifting or lengthy walks.
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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.
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.
The critical care nurse and the other members of the care team are assessing the patient to see if he is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify?
- A. Stable vital signs and ABGs
- B. Pulse oximetry above 80% and stable vital signs
- C. Stable nutritional status and ABGs
- D. Normal orientation and level of consciousness
Correct Answer: A
Rationale: Among many other predictors, stable vital signs and ABGs are important predictors of successful weaning. Pulse oximetry must greatly exceed 80%. Nutritional status is important, but vital signs and ABGs are even more significant. Patients who are weaned may or may not have full level of consciousness.
Postural drainage has been ordered for a patient who is having difficulty mobilizing her bronchial secretions. Before repositioning the patient and beginning treatment, the nurse should perform what health assessment?
- A. Chest auscultation
- B. Pulmonary function testing
- C. Chest percussion
- D. Thoracic palpation
Correct Answer: A
Rationale: Chest auscultation should be performed before and after postural drainage in order to evaluate the effectiveness of the therapy. Percussion and palpation are less likely to provide clinically meaningful data for the nurse. PFTs are normally beyond the scope of the nurse and are not necessary immediately before postural drainage.
The critical care nurse is precepting a new nurse on the unit. Together they are caring for a patient who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff?
- A. Deflate the cuff overnight to prevent tracheal tissue trauma
- B. Inflate the cuff to the highest possible pressure in order to prevent aspiration
- C. Monitor the pressure in the cuff at least every 8 hours
- D. Keep the tracheostomy tube plugged at all times
Correct Answer: C
Rationale: Cuff pressure must be monitored by the respiratory therapist or nurse at least every 8 hours by attaching a handheld pressure gauge to the pilot balloon of the tube or by using the minimal leak volume or minimal occlusion volume technique. Plugging is only used when weaning the patient from tracheal support. Deflating the cuff overnight would be unsafe and inappropriate. High cuff pressure can cause tissue trauma.