Chest Tubes
A nurse is checking the suction control chamber of a patient's chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?
What is verify that the suction regulator is on because low continual bubbling will occur when the suction is on and there are no kinks in the tubing?
A nurse is collecting data from a patient who is having an acute asthma exacerbation. When auscultating the patient's chest, the nurse should expect to hear which of the following sounds?
What is an expiratory wheeze because expiratory wheezing is associated with air movement through narrowed airways, as with the bronchospasm associated with asthma?
A nurse is collecting data from a patient who has emphysema. Which of the following findings should the nurse expect?
What is:
A nurse is preparing to review discharge instructions with a patient who has pulmonary tuberculosis. Which of the following information should the nurse include?
What is wear a mask while out or around crowds of people until the medication has suppressed the infection, which is determined by three consecutive negative sputum cultures?
A nurse is reinforcing teaching with a newly licensed nurse about the manifestations of hypoxia. Which of the following findings should the nurse include in the teaching?
What is agitation because the manifestations of hypoxia include agitation and restlessness due to neurological changes from poor oxygen exchange?
A nurse is assisting with the care of a patient who has multiple injuries following a motor vehicle crash. The nurse should monitor for which of the following manifestations of a pneumothorax?
What is absence of breath sounds because a patient who has a pneumothorax will have diminished or absent breath sounds on the affected side due to partial or total collapse of the lung?
A nurse in an urgent care center is caring for a patient who is having an acute asthma exacerbation. After administering high-flow oxygen, which of the following actions is the nurse’s highest priority?
What is administer a short-acting beta-adrenergic medication because the greatest risk to the patient’s safety is airway obstruction. Beta-adrenergic medications decrease the inflammatory response that triggers narrowing of the airways. They provide prompt relief of airflow obstruction and are the initial intervention when a patient has an acute asthma exacerbation; therefore, the priority action for the nurse to take is to administer a short-acting beta-adrenergic medication?
A nurse is reinforcing discharge teaching on actions that improve gas exchange to a patient diagnosed with emphysema. Which of the following instructions should be included in the teaching?
What is breathe in through her nose and out through pursed lips because this slows expiration, prevents collapse of alveoli, and helps the patient to control the rate and depth of respirations?
A nurse is collecting data from a patient who has pulmonary tuberculosis. Which of the following findings should the nurse expect?
What is fatigue because a patient who has pulmonary tuberculosis will have fatigue, night sweats, and a productive cough?
A nurse is caring for a patient who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this patient's secretions?
What is provide humidified oxygen because increasing fluid intake as tolerated and providing adequate humidification can help thin secretions safely?
The nurse is caring for a patient who has a pneumothorax and a water-seal chest tube drainage system to suction. Which of the following actions should the nurse take?
What is maintain the drainage container below the level of the patient's chest because keeping the drainage collection container below the level of the patient's chest prevents the back-flow of fluid into the patient's chest?
A nurse is admitting a patient who is having an exacerbation of asthma. When reviewing the provider's orders, the nurse recognizes that clarification is needed for which of the following prescribed medications?
What is Propranolol because the nurse should clarify a prescription for propranolol in a patient who has asthma. Medications that block beta-2 receptors, such as propranolol, are contraindicated in patients who have asthma because they result in bronchoconstriction of the airways?
A nurse is reinforcing teaching about self-management strategies with a patient who has emphysema. Which of the following patient statements indicates that the patient understands the instructions?
What is "I will follow a diet high in calories and protein" because patients who have emphysema have greater-than-usual nutritional requirements for calories and protein and often need nutritional supplements between meals?
A nurse is caring for a patient who has tuberculosis and is about to start taking pyrazinamide. The nurse should identify that the patient needs which of the following tests while taking this medication therapy?
What is Liver function tests because pyrazinamide can cause hepatotoxicity; therefore, the provider should monitor the patient’s liver function regularly while taking this medication?
A nurse is caring for a patient who is scheduled to undergo thoracentesis. In which of the following positions should the nurse place the patient for the procedure?
What is sitting, leaning forward over the bedside table to ensure that the diaphragm is dependent. This facilitates the removal of accumulated fluid, which tends to pool in the bases of the pleural space?
A nurse is monitoring a patient who has just had a thoracentesis to remove pleural fluid. Which of the following clinical manifestations should indicate to the nurse the patient is experiencing a complication and the provider should be notified immediately?
What is an increased heart rate because patients can experience pulmonary edema or cardiovascular distress after mediastinal contents shift suddenly after the aspiration of a large amount of fluid. An increase in heart and respiratory rate, coughing up blood-tinged frothy sputum, along with tightness in the chest are some of the manifestations the patient can develop. Any of these signs should be reported to the provider?
A nurse is assessing a patient who has asthma and signs of central cyanosis. Which of the following is a reliable indicator of cyanosis?
What is the oral mucosa because the nurse should first monitor the patient’s oral mucosa, lips, and nail beds for manifestations of cyanosis because cyanosis is most evident in areas with minimal pigmentation?
A nurse is caring for a patient who has COPD. Which of the following actions should the nurse take?
What is encourage the patient to drink 8 glasses of water a day to thin bronchial secretions?
A nurse is assisting with the plan of care for a patient who has pneumonia and requires chest percussion, vibration, and postural drainage. Which of the following actions should the nurse plan to complete first?
What is auscultate lung fields because taking the airway, breathing, circulation (ABC) approach to patient care is to auscultate lung fields to determine which lung areas are most affected and would be the focus of the procedure?
A nurse suspects anaphylaxis when caring for a patient following the initial administration of an oral antibiotic. Which of the following is the priority intervention by the nurse?
What is check the client's respiratory rate because using the airway, breathing, circulation approach to patient care, the nurse places the priority on assessing the patient's lung sounds. Checking the patient's respiratory rate can determine if the patient is in respiratory distress.
A nurse is caring for a patient who has a three-chamber closed chest tube system. Which of the following should the nurse do after noticing a rise in the water seal with patient inspiration?
What is continue to monitor the patient because the nurse should expect the fluid in the water seal chamber to fluctuate with patient respiration. A failure to rise and fall indicates a flaw in the chest tube system?
A nurse is reinforcing teaching about use of a metered-dose inhaler (MD) with a patient who has a new diagnosis of asthma. Identify the sequence the patient should follow.
What is:
A nurse is collecting data from a patient who is experiencing an acute exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following findings should the nurse expect?
What is aPaCO2 48 mm Hg because a client who has COPD retains carbon dioxide due to airway restriction; therefore, the nurse should expect this patient to have a PaCO2 above the expected reference range. The oxygen level tends to remain below the expected value. The nurse should implement oxygen therapy cautiously, because high oxygen saturation will decrease the patient’s incentive to breathe.
A nurse is contributing to the care plan of an older adult patient who has pneumonia. Which of the following interventions should the nurse include in the plan?
What is encourage fluid intake of 2.5 L per day will assist in breaking up the consolidation in the lungs by thinning the mucous, allowing the patient to cough more effectively?
A nurse is caring for a patient who is postoperative and has developed atelectasis. Which of the following findings should the nurse expect?
What is increasing dyspnea because atelectasis is a closure or collapse of the alveoli due to obstruction or hypoventilation, causing shortness of breath and pleural pain.