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The nurse is preparing to suction a patient with an endotracheal tube. What should be the nurses first step in the suctioning process?
- A. Explain the suctioning procedure to the patient and reposition the patient
- B. Turn on suction source at a pressure not exceeding 120 mm Hg
- C. Assess the patients lung sounds and SAO2 via pulse oximeter
- D. Perform hand hygiene and don nonsterile gloves, goggles, gown, and mask
Correct Answer: C
Rationale: Assessment data indicate the need for suctioning and allow the nurse to monitor the effect of suction on the patients level of oxygenation. Explaining the procedure would be the second step; performing hand hygiene is the third step, and turning on the suction source is the fourth step.
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The nurse is performing patient education for a patient who is being discharged on mini-nebulizer treatments. What information should the nurse prioritize in the patients discharge teaching?
- A. How to count her respirations accurately
- B. How to collect serial sputum samples
- C. How to independently wean herself from treatment
- D. How to perform diaphragmatic breathing
Correct Answer: D
Rationale: Diaphragmatic breathing is a helpful technique to prepare for proper use of the small-volume nebulizer. Patient teaching would not include counting respirations and the patient should not wean herself from treatment without the involvement of her primary care provider. Serial sputum samples are not normally necessary.
The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess?
- A. Fluid intake for the last 24 hours
- B. Baseline arterial blood gas (ABG) levels
- C. Prior outcomes of weaning
- D. Electrocardiogram (ECG) results
Correct Answer: B
Rationale: Before weaning a patient from mechanical ventilation, it is most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the patient is tolerating the procedure. Other assessment parameters are relevant, but less critical. Measuring fluid volume intake and output is always important when a patient is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the patients record, and the nurse can refer to them before the weaning process begins.
The nurse has explained to the patient that after his thoracotomy, it will be important to adhere to a coughing schedule. The patient is concerned about being in too much pain to be able to cough. What would be an alternative nursing intervention for this client?
- A. Teach him postural drainage
- B. Teach him how to perform huffing
- C. Teach him to use a mini-nebulizer
- D. Teach him how to use a metered dose inhaler
Correct Answer: B
Rationale: The technique of huffing may be helpful for the patient with diminished expiratory flow rates or for the patient who refuses to cough because of severe pain. Huffing is the expulsion of air through an open glottis. Inhalers, nebulizers, and postural drainage are not substitutes for performing coughing exercises.
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.
A patients plan of care specifies postural drainage. What action should the nurse perform when providing this noninvasive therapy?
- A. Administer the treatment with the patient in a high Fowlers or semi-Fowlers position
- B. Perform the procedure immediately following the patients meals
- C. Apply percussion firmly to bare skin to facilitate drainage
- D. Assist the patient into a position that will allow gravity to move secretions
Correct Answer: D
Rationale: Postural drainage is usually performed two to four times per day. The patient uses gravity to facilitate postural draining. The skin should be covered with a cloth or a towel during percussion to protect the skin. Postural drainage is not administered in an upright position or directly following a meal.