Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes. Oxygen toxicity Blood pressure increase of 20 mm Hg from baseline Sets found in the same folderRecommended textbook solutions
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Hole's Human Anatomy and Physiology13th EditionDavid N. Shier, Jackie L. Butler, Ricki Lewis 1,402 solutions Anatomy and Physiology1st EditionOpenStax 599 solutions 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? Signs and symptoms of respiratory complications The nurse assesses the patient's 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 patient's airway and breathing. After suctioning a tracheostomy tube, the nurse assesses the client to determine the effectiveness of the suctioning. Which findings indicate that the airway is now patent? Effective breathing at a rate of 16 breaths/minute through the established airway Proper suctioning should produce a patent airway, as demonstrated by effective breathing through the airway at a normal respiratory rate of 12 to 20 breaths/minute. The other options suggest ineffective suctioning. A respiratory rate of 28 breaths/minute and accessory muscle use may indicate mild respiratory distress. Increased pulse rate, rapid respirations, and cyanosis are signs of hypoxia. Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds indicate respiratory secretion accumulation.
The client is postoperative for a total laryngectomy and has recovered from anesthesia. The client's respirations are 32 breaths/minute, blood pressure is 102/58, and pulse rate is 104 beats/minute. Pulse oximetry is 90%. The client is receiving humidified oxygen. To aid in the client's respiratory status, the nurse places the client in which of the following positions. Semi- Fowler's The client is in respiratory distress. The best position for the client who has a tracheostomy and recovered from anesthesia is semi-Fowler's. A nurse is planning care for a client after a tracheostomy. One of the client's goals is to overcome verbal communication impairment. Which intervention should the nurse include in the care plan? Encourage the client's communication attempts by allowing him time to select or write words. The nurse should allow ample time for the client to respond and shouldn't speak for him. She should use as many aids as possible to assist the client with communicating and encourage the client when he attempts to communicate. When the client is ready, the nurse can use a tracheostomy plug to facilitate speech. Making an effort to read the client's lips and answering questions for the client are inappropriate. A nurse is caring for a client after a thoracotomy for a lung mass. Which nursing diagnosis should be the first priority? Impaired gas exchange Impaired gas exchange should be the nurse's first priority. After ensuring that the client has adequate gas exchange, she can address the other diagnoses of Anxiety, Impaired physical mobility, and Deficient knowledge: Home Care. The nurse is caring for a patient following a wedge resection. While the nurse is assessing the patient's chest tube drainage system, constant bubbling is noted in the
water seal chamber. This finding indicates which of the following problems? Air leak The nurse needs to observe for air leaks in the drainage system; they are indicated by constant bubbling in the water seal chamber, or by the air leak indicator in dry systems with a one-way valve. Tidaling is fluctuation of the water level in the water seal that shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent. A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition? Hypoxia As the respiratory center in the brain becomes depressed, hypoxia occurs, producing wheezing, bradycardia, and a decreased respiratory rate. Delirium is a state of mental confusion characterized by disorientation to time and place. Hyperventilation (respiratory rate greater than that metabolically necessary for gas exchange) is marked by an increased respiratory rate or tidal volume, or both. Semiconsciousness is a state of impaired consciousness characterized by limited motor and verbal responses and decreased orientation. For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan? Measuring and documenting the drainage in the collection chamber The nurse should regularly measure and document the amount of chest tube drainage to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected. The nurse should keep the collection chamber below chest level to allow fluids to drain into it. The nurse shouldn't strip chest tubes because doing so may traumatize the tissue or dislodge the tube. 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? Measure the patient's oxygen saturation. The patient's response to suctioning is usually determined by performing chest auscultation and by measuring the patient's oxygen saturation. FET, incentive spirometry, and percussion are not normally used as evaluative techniques. When
performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods? 10 to 15 seconds In general, the nurse should apply suction no longer than 10 to 15 seconds because hypoxia and dysrhythmias may develop, leading to cardiac arrest. Applying suction for 30 to 35 seconds is hazardous and may result in the patient's developing hypoxia, which can lead to dysrhythmias and, ultimately, cardiac arrest. Applying suction for 20 to 25 seconds is hazardous and may result in the patient's developing hypoxia, which can lead to dysrhythmias and, ultimately, cardiac arrest. Applying suction for 0 to 5 seconds would provide too little time for effective suctioning of secretions. A client is receiving supplemental
oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? Partial pressure of arterial oxygen (PaO2) The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3-, and PaCO2 A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings? 84 mm Hg A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client? By supplying a magic slate or similar device The nurse should use a nonverbal communication method, such as a magic slate, note pad and pencil, and picture boards (if the client can't write or speak English). The physician orders a tracheostomy plug when a client is being weaned off a tracheostomy; it doesn't enable the client to communicate. The call button, which should be within reach at all times for all clients, can summon attention but doesn't communicate additional information. Suctioning clears the airway but doesn't enable the client to communicate. After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is
functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes? Water-seal chamber Fluctuations in the water-seal compartment are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respirations. The air-leak meter — not chamber — detects air leaking from the pleural space. The collection chamber connects the chest tube from the client to the system. Drainage from the tube drains into and collects in a series of calibrated columns in this chamber. The suction control chamber provides the suction, which can be controlled to provide negative pressure to the chest. The OR nurse is setting up a water-seal chest drainage system for a patient who has just had a
thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system? 20 cm H2O The amount of suction is determined by the water level. It is usually set at 20 cm H2O; adding more fluid results in more suction. 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? 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 The nurse is discussing activity management with a patient who is postoperative following thoracotomy. What instructions should the nurse give to the patient regarding activity immediately following discharge? Perform shoulder exercises five times daily. The nurse emphasizes the importance of progressively increased activity. The nurse also instructs the patient on the importance of performing shoulder exercises five times daily. The patient should ambulate with limits and realize that the return of strength will likely be gradual and likely will not include weight lifting or lengthy walks. 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? 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. 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 patient's needs? Nasal cannula 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 patient's respiratory status does not require a partial- or non-rebreathing mask. After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must: encourage coughing and deep breathing. When caring for a client who's recovering from a thoracotomy, the nurse should encourage coughing and deep breathing to prevent pneumonia. Fluctuations in the water-seal chamber are normal. Clamping the chest tube could cause a tension pneumothorax. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage. A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned? a) Have the patient cough. Auscultate the lung for adventitious sounds. When a tracheostomy or endotracheal tube is in place, it is usually necessary to suction the patient's secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are obviously present. Unnecessary suctioning can initiate bronchospasm and cause mechanical trauma to the tracheal mucosa. The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying? a) Hypoxic hypoxia Circulatory hypoxia Given this patient's vital signs, he appears to be in shock. Circulatory hypoxia is hypoxia resulting from inadequate capillary circulation. It may be caused by decreased cardiac output, local vascular obstruction, low-flow states such as shock, or cardiac arrest. Although tissue partial pressure of oxygen (PO2) is reduced, arterial oxygen (PaO2) remains normal. Circulatory hypoxia is corrected by identifying and treating the underlying cause. A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? a) Use of a cooling blanket Endotracheal suctioning Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected. The nurse is preparing to assist the health care provider with the removal of a patient's chest tube. Which of the following instructions will the nurse correctly give the patient? a) "Exhale forcefully while the
chest tube is being removed." "When the tube is being removed, take a deep breath, exhale, and bear down." When assisting in the chest tube's removal, instruct the patient to perform a gentle Valsalva maneuver or to breathe quietly. The chest tube is then clamped and quickly removed. Simultaneously, a small bandage is applied and made airtight with petrolatum gauze covered by a 4 × 4-inch gauze pad and thoroughly covered and sealed with nonporous tape. The other options are incorrect instructions for the patient. A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct? a)
"Don't use the incentive spirometer more than 5 times every hour." "Before you do the exercise, I'll give you pain medication if you need it." The nurse should assess the client's pain level before the client does incentive spirometry exercises and administer pain medication as needed. Doing so helps the client take deeper breaths and help prevents atelectasis. The client should breathe in slowly and steadily, and hold his breath for 3 seconds after inhalation. The client should start doing incentive spirometry immediately after surgery and aim to do 10 incentive spirometry breaths every hour. A client who must begin oxygen therapy asks the nurse why this treatment is necessary? What would the nurse identify as the goals of oxygen therapy? Select all that apply. a) To provide adequate transport of oxygen in the blood • To provide adequate transport of oxygen in the blood Oxygen therapy is designed to provide adequate transport of oxygen in the blood while decreasing the work of breathing and reducing stress on the myocardium. Incentive spirometry is a respiratory modality that provides visual feedback to encourage the client to inhale slowly and deeply to maximize lung inflation and prevent or reduce atelectasis. A mini-nebulizer is used to help clear secretions The nurse is teaching a postoperative client who had a coronary artery bypass graft about using the incentive spirometer. The nurse instructs the client to perform the exercise in the following order: 1 Sit in an upright position. Sit in an upright position. The nurse instructs the client, when using the incentive spirometer, the proper use of it. First, the client is to sit in an upright position. The client is then to place the mouthpiece of the spirometer in the client's mouth. Next, the client breathes air in through the mouth. This causes the incentive spirometer to be activated. The client holds his breath for about 3 seconds. Then, the client exhales slowly through the mouth. Of the following oxygen administration devices, which has the advantage of providing high oxygen concentration? a) Venturi mask Non-rebreather mask The non-rebreather mask provides high oxygen concentration but it is usually poor fitting. The Venturi mask provides low levels of supplemental oxygen. The catheter is an inexpensive device that provides a variable fraction of inspired oxygen and may cause gastric distention. A face tent provides a fairly accurate fraction of inspired oxygen, but is bulky and uncomfortable. It would not be the device of choice to provide high oxygen concentration. The nurse is assessing a patient who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the patient's respirations. How should the nurse best respond to this assessment finding? a) Document that the chest drainage system is operating as it is intended. Document that the chest drainage system is operating as it is intended. Fluctuation of the water level in the water seal shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent. No further action is needed. A nurse is caring for a client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do? a) Clamp the chest tube immediately. Place the end of the chest tube in a container of sterile saline. If a chest drainage system is disconnected, the nurse may place the end of the chest tube in a container of sterile saline or water to prevent air from entering the chest tube, thereby preventing negative respiratory pressure. The nurse should apply an occlusive dressing if the chest tube is pulled out — not if the system is disconnected. The nurse shouldn't clamp the chest tube because clamping increases the risk of tension pneumothorax. The nurse should tape the chest tube securely to prevent it from being disconnected, rather than taping it after it has been disconnected. The nurse received a client from the post-anesthesia care unit (PACU) who has a chest tube to a closed drainage system. Report from the PACU nurse included drainage in the chest tube at 80 mL of bloody fluid. Fifteen minutes after transfer from the PACU, the chest tube indicates drainage as pictured. The client is reporting pain at "8" on a scale of 0 to 10. The first action of the nurse is to: a) Administer prescribed pain medication. Assess pulse and blood pressure. The client has bled 120 mL of bloody drainage in the chest drainage system within 15 minutes. It is most important for the nurse to assess for signs and symptoms of hemorrhage, which may be indicated by a rapid pulse and decreasing blood pressure. The nurse may then lay the client in a flat position and notify the physician. A client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery is most likely to reverse these manifestations? a) Nasal cannula Nonrebreather mask A nonrebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask, face tent, and nasal cannula — deliver lower levels of FIO2. While caring for a patient with an endotracheal tube, the nurses recognizes that suctioning is required how often? a) When the nurse needs to stimulate the cough reflex When adventitious breath sounds are auscultated It is usually necessary to suction the patient's secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are present. Unnecessary suctioning, such as scheduling every 2 hours, can initiate bronchospasm and cause trauma to the tracheal mucosa. The nurse is caring for a patient following a thoracotomy. Which of the following findings requires immediate intervention by the nurse? a) Pain of 5 on a 1 to 10 pain scale Chest tube drainage of 190 mL/hr The nurse should monitor and document the amount and character of drainage every 2 hours. The nurse will notify the primary provider if drainage is 150 mL/hr or greater. The other findings are normal following a thoracotomy; no intervention is required. The nurse is transporting a patient with chest tubes to a treatment room. The chest tube becomes disconnected and falls between the bed rail. What is the priority action by the nurse? a) Clamp the chest tube close to the connection site. Cut the contaminated tip of the tube and insert a sterile connector and reattach. If the patient is lying on a stretcher and must be transported to another area, place the drainage system below the chest level. If the tubing disconnects, cut off the contaminated tips of the chest tube and tubing, insert a sterile connector in the cut ends, and reattach to the drainage system. Do not clamp the chest tube during transport. A patient is to receive an oxygen concentration of 70%. What is the best way for the nurse to deliver this concentration? a) A Venturi mask A partial rebreathing mask Partial rebreathing masks have a reservoir bag that must remain inflated during both inspiration and expiration. The nurse adjusts the oxygen flow to ensure that the bag does not collapse during inhalation. A high concentration of oxygen (50% to 75%) can be delivered because both the mask and the bag serve as reservoirs for oxygen. The other devices listed cannot deliver oxygen at such a high concentration. The nurse is caring for a patient who is scheduled for a lobectomy. Following the procedure, the nurse will plan care based on which of the following? a) The patient will return from surgery
with no drainage tubes. The patient will return to the nursing unit with two chest tubes. The nurse should plan for the patient to return to the nursing unit with two chest tubes intact. During a lobectomy, the lobe is removed, and the remaining lobes of the lung are re-expanded. Usually, two chest catheters are inserted for drainage. The upper tube is for air removal; the lower one is for fluid drainage. Sometimes, only one catheter is needed. The chest tube is connected to a chest drainage apparatus for several days. In general, chest drainage tubes are not used for the patient undergoing a) lobectomy. pneumonectomy. Usually, no drains are used for the pneumonectomy patient because the accumulation of fluid in the empty hemothorax prevents mediastinal shift. With lobectomy, two chest tubes are usually inserted for drainage, the upper tube for air and the lower tube for fluid. With wedge resection, the pleural cavity usually is drained because of the possibility of an air or blood leak. With segmentectomy, drains are usually used because of the possibility of an air or blood leak. The nurse is assessing a patient with chest tubes connected to a drainage system. What should the first action be when the nurse observes excessive bubbling in the water seal chamber? a) Disconnect the system and get another. Notify the physician. Observe for air leaks in the drainage system; they are indicated by constant bubbling in the water seal chamber, or by the air leak indicator in dry systems with a one-way valve. In addition, assess the chest tube system for correctable external leaks. Notify the primary provider immediately of excessive bubbling in the water seal chamber not due to external leaks. The nurse is preparing to perform tracheostomy care on a patient with a newly inserted tracheostomy tube. Which of the following actions, if preformed by the nurse, indicates the need for further review of the procedure? a) Dries and reinserts the inner cannula or replaces it with a new disposable inner cannula Places clean tracheostomy ties, and removes soiled ties after the new ties are in place For a new tracheostomy, two people should assist with tie changes. The other actions, if performed by the nurse during tracheostomy care, are correct. The nurse is assigned the care of a patient with a chest tube. The nurse should ensure that which of the following items is kept at the patient's bedside? a) An incentive spirometer A bottle of sterile water It is essential that the nurse ensure that a bottle of sterile water is readily available at the patient's bedside. If the chest tube and drainage system become disconnected, air can enter the pleural space, producing a pneumothorax. To prevent the development of a pneumothorax, a temporary water seal can be established by immersing the chest tube's open end in a bottle of sterile water. There is no need to have an Ambu bag, incentive spirometer, or a set of hemostats at the bedside. A nurse educator is reviewing the indications for chest drainage systems with a group of medical nurses. What indications should the nurses identify? Select all that apply. a) Chest trauma resulting in pneumothorax • Post thoracotomy Chest drainage systems are used in treatment of spontaneous pneumothorax and trauma resulting in pneumothorax. Postural drainage and pleurisy are not criteria for use of a chest drainage system. Air leak Constant bubbling in the water seal of a chest drainage system indicates which of the following problems? a) Tension pneumothorax |
Which oxygen administration device has the advantage of providing a high oxygen concentration quizlet?
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