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The OR nurse is setting up a water-seal chest drainage system for a patient who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system?
- A. 20 cm H2O
- B. 15 cm H2O
- C. 10 cm H2O
- D. 5 cm H2O
Correct Answer: A
Rationale: The amount of suction is determined by the water level. It is usually set at 20 cm H2O; adding more fluid results in more suction.
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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 nurse is preparing to discharge a patient after thoracotomy. The patient is going home on oxygen therapy and requires wound care. As a result, he will receive home care nursing. What should the nurse include in discharge teaching for this patient?
- A. Safe technique for self-suctioning of secretions
- B. Technique for performing postural drainage
- C. Correct and safe use of oxygen therapy equipment
- D. How to provide safe and effective tracheostomy care
Correct Answer: C
Rationale: Respiratory care and other treatment modalities (oxygen, incentive spirometry, chest physiotherapy [CPT], and oral, inhaled, or IV medications) may be continued at home. Therefore, the nurse needs to instruct the patient and family in their correct and safe use. The scenario does not indicate the patient needs help with suctioning, postural drainage, or tracheostomy care.
While caring for a patient with an endotracheal tube, the nurses recognizes that suctioning is required how often?
- A. Every 2 hours when the patient is awake
- B. When adventitious breath sounds are auscultated
- C. When there is a need to prevent the patient from coughing
- D. When the nurse needs to stimulate the cough reflex
Correct Answer: B
Rationale: It is usually necessary to suction the patients secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are present. Unnecessary suctioning, such as scheduling every 2 hours, can initiate bronchospasm and cause trauma to the tracheal mucosa.
A patient with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the physician to order?
- A. Non-rebreather air mask
- B. Tracheostomy collar
- C. Venturi mask
- D. Face tent
Correct Answer: C
Rationale: The Venturi mask provides the most accurate method of oxygen delivery. Other methods of oxygen delivery include the aerosol mask, tracheostomy collar, and face tents, but these do not match the precision of a Venturi mask.
A nurse has performed tracheal suctioning on a patient who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention?
- A. Determine whether the patient can now perform forced expiratory technique (FET)
- B. Percuss the patients lungs and thorax
- C. Measure the patients oxygen saturation
- D. Have the patient perform incentive spirometry
Correct Answer: C
Rationale: The patients response to suctioning is usually determined by performing chest auscultation and by measuring the patients oxygen saturation. FET, incentive spirometry, and percussion are not normally used as evaluative techniques.