Nokea
While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of the patients closed chest-drainage system. What should the nurse conclude?
- A. The system is functioning normally
- B. The patient has a pneumothorax
- C. The system has an air leak
- D. The chest tube is obstructed
Correct Answer: C
Rationale: Constant bubbling in the chamber often indicates an air leak and requires immediate assessment and intervention. The patient with a pneumothorax will have intermittent bubbling in the water-seal chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.
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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.
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.
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 home care nurse is visiting a patient newly discharged home after a lobectomy. What would be most important for the home care nurse to assess?
- A. Resumption of the patients ADLs
- B. The familys willingness to care for the patient
- C. Nutritional status and fluid balance
- D. Signs and symptoms of respiratory complications
Correct Answer: D
Rationale: The nurse assesses the patients adherence to the postoperative treatment plan and identifies acute or late postoperative complications. All options presented need assessment, but respiratory complications are the highest priority because they affect the patients airway and breathing.
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.