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What would the critical care nurse recognize as a condition that may indicate a patients need to have a tracheostomy?
- A. A patient has a respiratory rate of 10 breaths per minute
- B. A patient requires permanent ventilation
- C. A patient exhibits symptoms of dyspnea
- D. A patient has respiratory acidosis
Correct Answer: B
Rationale: A tracheostomy permits long-term use of mechanical ventilation to prevent aspiration of oral and gastric secretions in the unconscious or paralyzed patient. Indications for a tracheostomy do not include a respiratory rate of 10 breaths per minute, symptoms of dyspnea, or respiratory acidosis.
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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 critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this patient is necessary. What is the main rationale for this?
- A. Maintaining a patent airway
- B. Preventing the need for suctioning
- C. Maintaining the sterility of the patients airway
- D. Increasing the patients lung compliance
Correct Answer: A
Rationale: Maintaining a patent (open) airway is achieved through meticulous airway management, whether in an emergency situation such as airway obstruction or in long-term management, as in caring for a patient with an endotracheal or a tracheostomy tube. The other answers are incorrect.
The nurse is performing nasotracheal suctioning on a medical patient and obtains copious amounts of secretions from the patients airway, even after inserting and withdrawing the catheter several times. How should the nurse proceed?
- A. Continue suctioning the patient until no more secretions are obtained
- B. Perform chest physiotherapy rather than nasotracheal suctioning
- C. Wait several minutes and then repeat suctioning
- D. Perform postural drainage and then repeat suctioning
Correct Answer: C
Rationale: If additional suctioning is needed, the nurse should withdraw the catheter to the back of the pharynx, reassure the patient, and oxygenate for several minutes before resuming suctioning. Chest physiotherapy and postural drainage are not necessarily indicated.
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.
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.