Acute Respiratory Disorders, Chest Tubes, and Mechanical Ventilation NCLEX

Acute Respiratory Disorders, Chest Tubes, and Mechanical Ventilation NCLEX Leave the first rating Students also studied Terms in this set (37) Save Cancer & Oncology Nursing NCLEX ...50 terms dwren47Preview Mark Klimek Blue Book Part 1 1,994 terms srauh1Preview Cancer nclex questions 26 terms Sarah_Crum3Preview NCLEX 133 term Fam The student nurse diligently assesses her patient with a chest tube. She notices that the suction control chamber of the chest tube is not bubbling. What is the first thing this student should do?

• Document this normal finding
• Encourage the patient to cough and deep breathe
• Check the level of the suction on the wall
• Clamp the chest tube and call for help

Answer: C. The level of suction is controlled by the amount of water in the suction control chamber. However, it would be prudent of the student nurse to check and see if the suction is even turned on. This portion of the chest tube should be gently bubbling, indicating the system is working. Coughing and deep breathing would not help turn the suction on. The student should never clamp the chest tube.The nurse sees the level of water in the water seal chamber rising very high. The nurse correlates which patient behavior with this rise?

• The patient is eating his lunch
• The patient is resting on his side
• The patient is squeezing the tubing
• The patient is coughing viciously.

Answer: D. Coughing, sneezing or other forces can cause an increase in negative

pressure which will in turn cause an increase in the water in the water seal chamber. Eating or resting should not affect the negative pressure in the tube.Squeezing, kinking, or somehow cutting off the flow into the chest tube would increase positive pressure, not negative.You are the nursing instructor and you are taking your students to a unit where chest tubes are often in use.Which statement, if made by your students, is correct?

• "If a clot has formed in the tubing, it can be gently

milked by fully completely compressing the tubing and milking it into the drainage container"

• "I should loop my patients tubing in order to keep it off

of the floor"

• "Because my patient has a tube draining air out of their

pleural space, it will not be necessary to have them use their incentive spirometer"

• "There can be an occasional bubble form in the water

seal chamber of the chest tube"

Answer: D. An occasional bubble formed in the water seal chamber indicates that

air is being released from the pleural spaces. Gentle milking of the tube may be permitted, but the tube should never be fully compressed to do it. Looping or kinking of the tube may cause a backward pressure that could impede drainage or force air back into the pleural spaces. Incentive spirometer use will help improve lung expansion.

You walk into the patient's room and witness the patient disconnecting the chest tube. What should the nurse do right away?

• Administer 02 and clamp the tube
• Reconnect the chest tube by using a sterile connector

piece

• Call the physician
• Cover the tube with a piece of sterile gauze

Answer: B. The nurse can reconnect the chest tube by cutting the contaminated

piece and using a sterile reconnecting piece to reattach the chest tube (page 317). The nurse can also place the end of the tube in sterile water. The nurse should never clamp the tube except when changing the box.You, the nurse, have been monitoring the client with subcutaneous emphysema around the shoulder and lower neck. You notice that the area has expanded and is traveling up the neck. Based on your knowledge, what should the nurse anticipate doing in the near future?

• Preparing the client for surgery
• Encouraging the client to use the IS
• Palpating the area
• Assisting with tracheostomy insertion

Answer: D. Subcutaneous emphysema is benign unless it spreads up into the

throat and airway. In this event, a tracheostomy may need to be inserted in order to keep the airway open. Encouraging the pt. to use incentive spirometry or palpate the area will not help protect the client's airway or get rid of the subcutaneous emphysema.A patient enters the ED presenting with symptoms of shortness of breath, severe chest pain, and diminished heart sounds. His blood pressure is 90/70 and his heart rate is 110. You notice that the trachea appears to be deviated to the right. What is your nursing priority?

• Prepare for an emergency insertion of a needle into

the second intercostal space, midclavicular line

• Hang IV fluids and prepare for chest tube insertion
• Encourage patient to breathe into a paper bag and

obtain ABG's.

• Assess for allergies and administer epinephrine as

ordered Answer: A. This patient is presenting with symptoms of a tension pneumothorax. In this emergent situation, a needle can be inserted at the second intercostal space, midclavicular line to immediately allow some air to flow out of the pleural space. A chest tube would then be inserted. The lung re-expansion would correct the abnormal blood pressure and heart rate, and the patient does not appear to be having an allergic reaction.The patient has been diagnosed with having an open pneumothorax r/t penetrating injury. Which of the following symptoms would the nurse most expect to see in this patient?

• Chest pain and tracheal shifting
• Hyperresanance and hyperexpansion of the affected

side

• High pitched respiratory sounds and SpO2 89%
• Muffled heart sounds and bradycardia

Answer: C. An open pneumothorax is often also known as a sucking chest wound,

producing a high pitched sucking sound coming from the wound. Diminished oxygen level, hyperresanance, and chest pain would also be expected in this patient. Tracheal shifting and hyperexpansion of the lung may be seen in a tension pneumothorax (an unlikely development of an open pneumothorax). Tachycardia, rather than bradycardia would be a common symptom in pneumothorax.The nurse is taking care of the patient with a pneumothorax. Which of the following, if found in the patients history, would be most contributory to the development of this pneumothorax?

• MVA involvement approximately 2 weeks ago.
• Hx of diabetes, HTN, and asthma
• Insertion of subclavian line yesterday
• Daily use of albuterol and corticosteroid inhaler

Answer: C. Insertion of a subclavian line is often associated with traumatic

pneumothorax. Some other procedures that may also cause this condition include throracentesis, endotracheal intubation, or transbronchial lung biopsy.

Which of the following nursing diagnoses would be the most important yet relevant nursing diagnosis for the patient diagnosed with having a pulmonary contusion?

• Fluid Volume Overload

B) Imbalanced Nutrition: Less than body requirements

• Acute Pain
• Risk for Infection

Answer: A. Fluid volume overload would be appropriate for this client because of the fluid build-up occurring in the lungs (AEB: Crackles, decreased breath sounds, etc.). This build-up is caused by the bruising and edema pulling fluid from the vascular spaces.The nurse enters the patient's room at the beginning of her shift. The patient is 3 days post-op right-sided pneumonectomy. Which of the following findings requires most immediate intervention by the nurse?1) The patient is slowly sipping iced water.2) The CNA reports that urinary output for the last 6 hours is 200 mL.3) The patient is positioned on her left side with SCDs in place.4) The patient reports pain at 9/10.

Answer: 3)

The post-op pneumonectomy patient should be positioned on the OPERATIVE (bad) side OR on the back. Sipping iced water in itself isn't harmful to this patient.Urinary output is sufficient. Pain is expected, although this would be the nurse's second concern.A nurse knows that which of the following is the most important item required at the bedside of a patient with an endotracheal tube at all times?1) A 4x4 piece of sterile gauze and a 100 mL container of sterile water.2) A portable chest X-ray machine with a lead vest.3) A soft-bristled toothbrush and chlorahexadine-based oral care supplies.4) An Ambu bag

Answer: 4)

An ambu bag and suction catheters/suction sources must be at the bedside of patients with artificial airways.The nurse is caring for a patient with a tracheostomy tube.Which action, if performed by the nurse, is incorrect and requires intervention from the charge nurse?1) The nurse suctions the patient's airway when she hears noisy respirations.2) The nurse inflates the trach cuff to 30 cm H2O.3) The nurse ensures that there is an obturator at the patient's bedside.4) The nurse asks that another nurse help her while she changes the tracheostomy ties for the first time.

Answer: 2)

Excessive cuff pressure can cause tracheal necrosis, limit blood flow, and compress tracheal capillaries.A patient admits to the E.D. with fractures of 3 lower ribs.Which of the following is the priority concern of the nurse caring for this patient?1) infection risk 2) pain 3) hemorrhage risk 4) airway maintenance

Answer: 3)

Hemorrhage risk is our priority concern, due to the possibility of liver and spleen injuries. Although airway maintenance is a concern with all patients, the priority and most relevant concern with this particular patient is monitoring for signs and symptoms of hemorrhage.

A 19 year-old patient being administered PEEP begins to have copious amounts of secretions that she says she "just cannot cough up." Which of the following nursing actions is most appropriate at this time?1) Assess the patient further and utilize bedside suction equipment.2) Assess O2 sats and continue to monitor patient if results are 95% or above.3) Obtain respiratory therapy consult.4) Obtain an order for a mucolytic agent from the physician.

Answer: 3)

At this time, the nurse should obtain a respiratory therapy consult. Any break in the closed ventilator system causes the loss of PEEP, so respiratory therapy needs to be consulted to add in-line suctioning.A nurse enters the room of a patient with a left-sided pneumothorax to perform an afternoon assessment. The nurse finds the patient's trachea deviated slightly to the right side compared to her morning findings, and the patient reports feeling increasingly short of breath. What is the first action the nurse should take?1) Administer high-flow supplemental oxygen.2) Position the patient's HOB at 30-45 degrees.3) Call the physician.4) Document the extent of tracheal shift in the patient's chart and reassess in 15 minutes.1) High-flow supplemental oxygen should be administered immediately to offset the unavoidable result of hypoxemia. The nurse should also ensure a POX is applied.Adjusting the HOB will not adequately relieve the patient's shortness of breath.A nurse is caring for an agitated and anxious patient who was intubated 6 hours ago and is now on mechanical ventilation. Communication efforts to calm the patient have failed, and the nurse is now turning to pharmacological intervention. Which medication does the nurse anticipate administering?1) Lorazepam 2) Morphine sulfate 3) Pancuronium 4) Fentanyl 1) Although Pancuronium (a neuromuscular blocking agent) CAN be used, it is best to try a sedative first. If satisfactory oxygen levels still cannot be maintained, then a neuromuscular blocking agent (WITH PAIN MEDICATION AND SEDATION!) can be used.The nurse knows that which of the following conditions would most likely contribute to the development of ARDS?

• Simple Pneumothorax
• Right Lobular Pulmonary Contusion
• Cardiac Tamponade
• Subcutaneous Emphysema

Answer: B. Pulmonary contusion causes fluid build-up to occur in the lungs which can in-turn impair gas exchange and and prevent oxygen and CO2 exchange. This fluid build-up can contribute to the development of ARDS (Acute Respiratory Distress Syndrome). This is the MOST likely to contribute this disorder.Which of the following would the nurse anticipate being

ordered for the patient with pulmonary contusion? SATA:

• IV fluids
• Intubation/mechanical ventilation
• Opioids
• Antibiotics
• Albumin

Answer: A, B, C, and D. IV fluids would be necessary to prevent hypovolemia

because of the fluid that is leaving the vascular spaces into the lungs/pleural spaces. This must be administered judiciously to prevent fluid volume overload or worsening lung function. Intubation or mechanical ventilation may be ordered, if pulmonary contusion is severe. Opioids are often used for pain relief. Antibiotics would be administered prophylactically to prevent infection from arising. Albumin would not be given in this disorder.