Symptoms
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient has been receiving high-flow oxygen therapy for an extended time. What symptoms should the nurse anticipate if the patient were experiencing oxygen toxicity?
A) Bradycardia and frontal headache
B) Dyspnea and substernal pain
C) Peripheral cyanosis and restlessness D) Hypotension and tachycardia
B) Dyspnea and substernal pain
Oxygen toxicity can occur when patients receive too high a concentration of oxygen for an extended period. Symptoms of oxygen toxicity include dyspnea, substernal pain, restlessness, fatigue, and progressive respiratory difficulty. Bradycardia, frontal headache, cyanosis, hypotension, and tachycardia are not symptoms of oxygen toxicity.
The nurse caring for a patient with an endotracheal tube recognizes several disadvantages of an endotracheal tube. What would the nurse recognize as a disadvantage of endotracheal tube
A) Cognition is decreased.
B) Daily arterial blood gases (ABGs) are necessary.
C) Slight tracheal bleeding is anticipated.
D) The cough reflex is depressed.
D) The cough reflex is depressed.
There are several disadvantages of an endotracheal tube. Disadvantages include suppression of the patients cough reflex, thickening of secretions, and depressed swallowing reflexes. Ulceration and stricture of the larynx or trachea may develop, but bleeding is not an expected finding. The tube should not influence cognition and daily ABGs are not always required.
A patients plan of care specifies postural drainage. What action should the nurse perform when providing this noninvasive therapy?
A) Administer the treatment with the patient in a high Fowlers or semi-Fowlers position.
B) Perform the procedure immediately following the patients meals.
C) Apply percussion firmly to bare skin to facilitate drainage.
D) Assist the patient into a position that will allow gravity to move secretions.
D) Assist the patient into a position that will allow gravity to move secretions.
Postural drainage is usually performed two to four times per day. The patient uses gravity to facilitate postural draining. The skin should be covered with a cloth or a towel during percussion to protect the skin. Postural drainage is not administered in an upright position or directly following a meal.
A nurse is educating a patient in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the patient and the family that this drainage system is used for?
A) Maintaining positive chest-wall pressure
B) Monitoring pleural fluid osmolarity
C) Providing positive intrathoracic pressure
D) Removing excess air and fluid
D) Removing excess air and fluid
Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. They are not used to maintain positive chest-wall pressure, monitor pleural fluid, or provide positive intrathoracic pressure.
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.
B) A patient requires permanent ventilation.
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.
A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube?
A) To remove air from the pleural space
B) To drain copious sputum secretions
C) To monitor bleeding around the lungs
D) To assist with mechanical ventilation
A) To remove air from the pleural space
Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. The primary purpose of a chest tube is not to drain sputum secretions, monitor bleeding, or assist with mechanical ventilation.
The medical nurse is creating the care plan of an adult patient requiring mechanical ventilation. What nursing action is most appropriate?
A) Keep the patient in a low Fowlers position.
B) Perform tracheostomy care at least once per day.
C) Maintain continuous bedrest.
D) Monitor cuff pressure every 8 hours.
D) Monitor cuff pressure every 8 hours.
The cuff pressure should be monitored every 8 hours. It is important to perform tracheostomy care at least every 8 hours because of the risk of infection. The patient should be encouraged to ambulate, if possible, and a low Fowlers position is not indicated.
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
B) How to splint the incision when coughing
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.