Trach Care
33. A nurse is suctioning fluids from a male client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of:
A. 1 minute
B. 5 seconds
C. 10 seconds
D. 30 seconds
C
10-15 seconds
After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must:
a) report fluctuations in the water-seal chamber.
b) clamp the chest tube once every shift.
c) encourage coughing and deep breathing.
d) milk the chest tube every 2 hours.
c
24. Nurse Reese is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment of this client?
A. Hypocapnia
B. A hyperinflated chest noted on the chest x-ray
C. Increased oxygen saturation with exercise
D. A widened diaphragm noted on the chest x-ray
B
They are retaining CO2 from poor gas exchange - so you would see hypercapnia. You would see decrease oxygen with exercise. The diaphragm would be flattened from the constant hyperinflated chest.
42. A male client is asking the nurse a question regarding the Mantoux test for tuberculosis. The nurse should base her response on the fact that the:
A. Area of redness is measured in 3 days and determines whether tuberculosis is present.
B. Skin test doesn’t differentiate between active and dormant tuberculosis infection.
C. Presence of a wheal at the injection site in 2 days indicates active tuberculosis.
D. Test stimulates a reddened response in some clients and requires a second test in 3 months.
B
Remember the test doesn't tell whether you have active or latent; therefore a and c are wrong. A reddened border of >10mm is healthy, you would have to get a chest x-ray and sputum test (not wait 3 months)
12. When caring for a male patient who has just had a total laryngectomy, the nurse should plan to:
A. Encourage oral feeding as soon as possible
B. Develop an alternative communication method
C. Keep the tracheostomy cuff fully inflated
D. Keep the patient flat in bed
B
trach cuff pressure should be 20-25 (not FULLY inflated => cause necrosis or ischemia)
Oral feedings need to wait until pt cleared to swallow
The nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is:
a) helping him communicate.
b) keeping his airway patent.
c) encouraging him to perform activities of daily living.
d) preventing him from developing an infection.
B
ABC's! Airway patent first!
59. After undergoing a thoracotomy, a male client is receiving epidural analgesia. Which assessment finding indicates that the client has developed the most serious complication of epidural analgesia?
A. Heightened alertness
B. Increased heart rate
C. Numbness and tingling of the extremities
D. Respiratory depression
D
think MOST serious (I think what is going to kill the patient first - airway always!)
14. For a patient with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange?
A. Encouraging the patient to drink three glasses of fluid daily
B. Keeping the patient in semi-Fowler’s position
C. Using a high-flow venture mask to deliver oxygen as prescribe
D. Administering a sedative, as prescribe
C
Sedatives would lower RR.
Think the question is asking BEST GAS exchange = delivering a precise amount of oxygen would help that, pt would benefit in high fowler's postition
50. A male client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can’t produce an effective cough, the nurse should monitor closely for:
A. Pleural effusion.
B. Pulmonary edema.
C. Atelectasis.
D. Oxygen toxicity.
C
he cannot take deep breaths and cough to open the aveoli, he is at risk for atelectasis
47. The nurse assesses a male client’s respiratory status. Which observation indicates that the client is experiencing difficulty breathing?
A. Diaphragmatic breathing
B. Use of accessory muscles
C. Pursed-lip breathing
D. Controlled breathing
B
The other 3 are techniques to help deep breathing
A client has just arrived in the PACU following a successful tracheostomy procedure. Which nursing action must be taken first?
A. Suction as needed
B. Clean the tracheostomy inner cannula and stoma
C. Listen to lung sounds
D. Change the tracheostomy dressing as needed
c
FIRST priority
lung sounds to make sure the trach is working appropriately and they have a patent airway
Two hours after surgery the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 mL of dark-red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform?
A: Record the amount and continue to monitor drainage
B: Notify the health care provider
C: Strip the chest tube starting at the chest
D: Increase the suction by 10 mm Hg
A
blood for the first few days is a normal finding
51. The nurse in charge is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide?
A. It helps prevent early airway collapse.
B. It increases inspiratory muscle strength.
C. It decreases use of accessory breathing muscles.
D. It prolongs the inspiratory phase of respiration.
A
the expiratory phase is longer in pursed lips, not inspiratory (3 sec:7sec) - helps eliminate CO2
it helps prevent collapse by controlling respirations in times of stress.
A woman whose husband was recently diagnosed with active pulmonary tuberculosis (TB) is a tuberculin skin test converter. Management of her care would include:
a) scheduling her for annual tuberculin skin testing.
b) placing her in quarantine until sputum cultures are negative.
c) gathering a list of persons with whom she has had recent contact.
d) advising her to begin prophylactic therapy with isoniazid (INH).
D
All family members should prophylactically take meds for TB
A nurse teaches a male client about the use of a respiratory inhaler. Which action by the client indicates a need for further teaching?
a. Inhales the mist and quickly exhales
b. Removes the cap and shakes the inhaler well before use
c. Presses the canister down with the finger as he breathes in
d. Waits 1 to 2 minutes between puffs if more than one puff has been prescribed
A
inhales and hold breath for 10-15sec, then exhale slowly
34. A nurse is suctioning fluids from a female client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which if the following is the appropriate nursing intervention?
A. Continue to suction
B. Notify the physician immediately
C. Stop the procedure and reoxygenate the client
D. Ensure that the suction is limited to 15 seconds
C
when suctioning - it can trigger your vagal response = lower HR, BP, coughing. Stop the procedure and reoxygenate pt. The pt should return to baseline, if continued low HR and BP then contact provider.
The client has a right-sided chest tube. As the client is getting out of the bed it is accidentally pulled out of the pleural space. Which action should the nurse implement first?
1. Notify the health-care provider to have chest tubes reinserted STAT.
2. Instruct the client to take slow shallow breaths until the tube is reinserted.
3. Take no action and assess the client's respiratory status every 15 minutes.
4. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site.
D
pulled out the pleural space (the chest)
vs a question that states disconnected from the chest tube system = put tube in sterile water
A patient's partner informs the nurse that the patient wakes up with a startle and gasps for breath several times at night. The nurse understands the patient is experiencing sleep apnea. What are the common risk factors in this patient for sleep apnea? Select all that apply.
A Body mass index (BMI) 30 kg/m2
B Age 44 years
C Habit of smoking
D.Neck circumference 18 inches
E .Occasional consumption of alcohol
a c d
After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's teenage daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy?
a) 3 to 5 days
b) 1 to 3 weeks
c) 2 to 4 months
d) 6 to 12 month
D
Two months (first phase)
Four months (second phase)
can be longer if needed
A female client has just returned to a nursing unit following bronchoscopy. A nurse would implement which of the following nursing interventions for this client?
a. Administering atropine intravenously
b. Administering small doses of midazolam (Versed)
c. Encouraging additional fluids for the next 24 hours
d. Ensuring the return of the gag reflex before offering food or fluids
D
very important to be NPO until gag reflex is intact and swallowing has been assessed
A patient has a recent tracheostomy. What necessary equipment does the nurse ensure is kept at the bedside? Select all that apply.
A. ambu bag
B. pair of wire cutters
C. oxygen tubing
D. suction equipment
E. tracheostomy tube with obturator
A C D E
The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply.
1.Excessive bubbling in the water seal chamber
2.Vigorous bubbling in the suction control chamber
3.Drainage system maintained below the client's chest
4.50 mL of drainage in the drainage collection chamber
5.Occlusive dressing in place over the chest tube insertion site
6.Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation
3 4 5 6
look at #2 - the SUCTION control chamber is normal to have continuous bubbling but not vigorous
the water seal chamber should have INTERMITTENT
A client with chronic obstructive pulmonary disease (COPD) is being evaluated for a lung transplant. The nurse performs the initial physical assessment. Which signs and symptoms should the nurse expect to find?
a) Decreased respiratory rate
b) Dyspnea on exertion
c) Barrel chest
d) Shortened expiratory phase
e) Clubbed fingers and toes
f) Fever
b
c
e
12. Which percussion note would you hear over the airless area in atelectasis?
a. dull
b. resonant
c. flat
d. hyperresonant
A
No air movement = dull
Patients with a tracheostomy or endotracheal tube need suctioning. Which nursing interventions apply to proper suctioning technique? Select all that apply
A. preoxygenate the patient for at least 30 seconds before suctioning
B. Instruct the patient that he or she is going to be suctioned
C. quickly insert the suction catheter until resistance is met
D. suction the patient for at least 30 seconds to remove secretions
E. repeat suctioning as needed for to five total suction passes
A B C
Should only suction 15 seconds
only suction 2 times