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Chapter 21: Respiratory Care Modalities
1.
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
Ans:
B
Feedback:
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.
2.
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 tubes?
A)
Cognition is decreased.
B)
Daily arterial blood gases (ABGs) are necessary.
C)
Slight tracheal bleeding is anticipated.
D)
The cough reflex is depressed.
Ans:
D
Feedback:
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.
3.
What would the critical care nurse recognize as a condition that may indicate a patients need to have a
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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.
Ans:
B
Feedback:
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.
4.
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.
Ans:
D
Feedback:
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.
5.
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
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How to take prophylactic antibiotics correctly
D)
How to manage the need for fluid restriction
Ans:
B
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Feedback:
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.
6.
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
Ans:
D
Feedback:
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.
7.
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
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A
Feedback:
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.
8.
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.
Ans:
D
Feedback:
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.
9.
The critical care nurse is precepting a new nurse on the unit. Together they are caring for a patient who
has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care
nurse recommend when caring for the cuff?
A)
Deflate the cuff overnight to prevent tracheal tissue trauma.
B)
Inflate the cuff to the highest possible pressure in order to prevent aspiration.
C)
Monitor the pressure in the cuff at least every 8 hours
D)
Keep the tracheostomy tube plugged at all times.
Ans:
C
Feedback:
Cuff pressure must be monitored by the respiratory therapist or nurse at least every 8 hours by attaching
a handheld pressure gauge to the pilot balloon of the tube or by using the minimal leak volume or
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minimal occlusion volume technique. Plugging is only used when weaning the patient from tracheal
support. Deflating the cuff overnight would be unsafe and inappropriate. High cuff pressure can cause
tissue trauma.
10. The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter
is most important for the nurse to assess?
A)
Fluid intake for the last 24 hours
B)
Baseline arterial blood gas (ABG) levels
C)
Prior outcomes of weaning
D)
Electrocardiogram (ECG) results
Ans:
B
Feedback:
Before weaning a patient from mechanical ventilation, it is most important to have baseline ABG levels.
During the weaning process, ABG levels will be checked to assess how the patient is tolerating the
procedure. Other assessment parameters are relevant, but less critical. Measuring fluid volume intake
and output is always important when a patient is being mechanically ventilated. Prior attempts at
weaning and ECG results are documented on the patients record, and the nurse can refer to them before
the weaning process begins.
11. While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of the
patients closed chest-drainage system. What should the nurse conclude?
A)
The system is functioning normally.
B)
The patient has a pneumothorax.
C)
The system has an air leak.
D)
The chest tube is obstructed.
Ans:
C
Feedback:
Constant bubbling in the chamber often indicates an air leak and requires immediate assessment and
intervention. The patient with a pneumothorax will have intermittent bubbling in the water-seal chamber.
If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal
chamber.
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12. A patient recovering from thoracic surgery is on long-term mechanical ventilation and becomes very
frustrated when he tries to communicate. What intervention should the nurse perform to assist the
patient?
A)
Assure the patient that everything will be all right and that remaining calm is the best strategy.
B)
Ask a family member to interpret what the patient is trying to communicate.
C)
Ask the physician to wean the patient off the mechanical ventilator to allow the patient to speak
freely.
D)
Express empathy and then encourage the patient to write, use a picture board, or spell words with
an alphabet board.
Ans:
D
Feedback:
If the patient uses an alternative method of communication, he will feel in better control and likely be
less frustrated. Assuring the patient that everything will be all right offers false reassurance, and telling
him not to be upset minimizes his feelings. Neither of these methods helps the patient to communicate.
In a patient with an endotracheal or tracheostomy tube, the family members are also likely to encounter
difficulty interpreting the patients wishes. Making them responsible for interpreting the patients gestures
may frustrate the family. The patient may be weaned off a mechanical ventilator only when the
physiologic parameters for weaning have been met.
13. The physician has ordered continuous positive airway pressure (CPAP) with the delivery of a patients
high-flow oxygen therapy. The patient asks the nurse what the benefit of CPAP is. What would be the
nurses best response?
A)
CPAP allows a higher percentage of oxygen to be safely used.
B)
CPAP allows a lower percentage of oxygen to be used with a similar effect.
C)
CPAP allows for greater humidification of the oxygen that is administered.
D)
CPAP allows for the elimination of bacterial growth in oxygen delivery systems.
Ans:
B
Feedback:
Prevention of oxygen toxicity is achieved by using oxygen only as prescribed. Often, positive endexpiratory pressure (PEEP) or CPAP is used with oxygen therapy to reverse or prevent microatelectasis,
thus allowing a lower percentage of oxygen to be used. Oxygen is moistened by passing through a
humidification system. Changing the tubing on the oxygen therapy equipment is the best technique for
controlling bacterial growth.
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14. The home care nurse is assessing a patient who requires home oxygen therapy. What criterion indicates
that an oxygen concentrator will best meet the needs of the patient in the home environment?
A)
The patient desires a low-maintenance oxygen delivery system that delivers oxygen flow rates up
to 6 L/min.
B)
The patient requires a high-flow system for use with a tracheostomy collar.
C)
The patient desires a portable oxygen delivery system that can deliver 2 L/min.
D)
The patients respiratory status requires a system that provides an FiO2 of 65%.
Ans:
C
Feedback:
The use of oxygen concentrators is another means of providing varying amounts of oxygen, especially in
the home setting. They can deliver oxygen flows from 1 to 10 L/min and provide an FiO2 of about 40%.
They require regular maintenance and are not used for high-flow applications. The patient desiring a
portable oxygen delivery system of 2L/min will benefit from the use of an oxygen concentrator.
15. While caring for a patient with an endotracheal tube, the nurses recognizes that suctioning is required
how often?
A)
Every 2 hours when the patient is awake
B)
When adventitious breath sounds are auscultated
C)
When there is a need to prevent the patient from coughing
D)
When the nurse needs to stimulate the cough reflex
Ans:
B
Feedback:
It is usually necessary to suction the patients 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.
16. The nurse is caring for a patient who is ready to be weaned from the ventilator. In preparing to assist in
the collaborative process of weaning the patient from a ventilator, the nurse is aware that the weaning of
the patient will progress in what order?
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A)
Removal from the ventilator, tube, and then oxygen
B)
Removal from oxygen, ventilator, and then tube
C)
Removal of the tube, oxygen, and then ventilator
D)
Removal from oxygen, tube, and then ventilator
Ans:
A
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Feedback:
The process of withdrawing the patient from dependence on the ventilator takes place in three stages: the
patient is gradually removed from the ventilator, then from the tube, and, finally, oxygen.
17. The nurse has admitted a patient who is scheduled for a thoracic resection. The nurse is providing
preoperative teaching and is discussing several diagnostic studies that will be required prior to surgery.
Which study will be performed to determine whether the planned resection will leave sufficient
functioning lung tissue?
A)
Pulmonary function studies
B)
Exercise tolerance tests
C)
Arterial blood gas values
D)
Chest x-ray
Ans:
A
Feedback:
Pulmonary function studies are performed to determine whether the planned resection will leave
sufficient functioning lung tissue. ABG values are assessed to provide a more complete picture of the
functional capacity of the lung. Exercise tolerance tests are useful to determine if the patient who is a
candidate for pneumonectomy can tolerate removal of one of the lungs. Preoperative studies, such as a
chest x-ray, are performed to provide a baseline for comparison during the postoperative period and to
detect any unsuspected abnormalities.
18. 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?
A)
Walk 1 mile 3 to 4 times a week.
B)
Use weights daily to increase arm strength.
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Walk on a treadmill 30 minutes daily.
D)
Perform shoulder exercises five times daily.
Ans:
D
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Feedback:
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.
19. A patient with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which
mask will the nurse expect the physician to order?
A)
Non-rebreather air mask
B)
Tracheostomy collar
C)
Venturi mask
D)
Face tent
Ans:
C
Feedback:
The Venturi mask provides the most accurate method of oxygen delivery. Other methods of oxygen
delivery include the aerosol mask, tracheostomy collar, and face tents, but these do not match the
precision of a Venturi mask.
20. 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 patients needs?
A)
Non-rebreathing mask
B)
Nasal cannula
C)
Simple mask
D)
Partial-rebreathing mask
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B
Feedback:
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 patients respiratory status does not require a partial- or nonrebreathing mask.
21. A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse
knows that meticulous airway management of this patient is necessary. What is the main rationale for
this?
A)
Maintaining a patent airway
B)
Preventing the need for suctioning
C)
Maintaining the sterility of the patients airway
D)
Increasing the patients lung compliance
Ans:
A
Feedback:
Maintaining a patent (open) airway is achieved through meticulous airway management, whether in an
emergency situation such as airway obstruction or in long-term management, as in caring for a patient
with an endotracheal or a tracheostomy tube. The other answers are incorrect.
22. The nurse is preparing to suction a patient with an endotracheal tube. What should be the nurses first
step in the suctioning process?
A)
Explain the suctioning procedure to the patient and reposition the patient.
B)
Turn on suction source at a pressure not exceeding 120 mm Hg.
C)
Assess the patients lung sounds and SAO2 via pulse oximeter.
D)
Perform hand hygiene and don nonsterile gloves, goggles, gown, and mask.
Ans:
C
Feedback:
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Assessment data indicate the need for suctioning and allow the nurse to monitor the effect of suction on
the patients level of oxygenation. Explaining the procedure would be the second step; performing hand
hygiene is the third step, and turning on the suction source is the fourth step.
23. The critical care nurse and the other members of the care team are assessing the patient to see if he is
ready to be weaned from the ventilator. What are the most important predictors of successful weaning
that the nurse should identify?
A)
Stable vital signs and ABGs
B)
Pulse oximetry above 80% and stable vital signs
C)
Stable nutritional status and ABGs
D)
Normal orientation and level of consciousness
Ans:
A
Feedback:
Among many other predictors, stable vital signs and ABGs are important predictors of successful
weaning. Pulse oximetry must greatly exceed 80%. Nutritional status is important, but vital signs and
ABGs are even more significant. Patients who are weaned may or may not have full level of
consciousness.
24. 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?
A)
20 cm H2O
B)
15 cm H2O
C)
10 cm H2O
D)
5 cm H2O
Ans:
A
Feedback:
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.
25. The nurse is preparing to discharge a patient after thoracotomy. The patient is going home on oxygen
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therapy and requires wound care. As a result, he will receive home care nursing. What should the nurse
include in discharge teaching for this patient?
A)
Safe technique for self-suctioning of secretions
B)
Technique for performing postural drainage
C)
Correct and safe use of oxygen therapy equipment
D)
How to provide safe and effective tracheostomy care
Ans:
C
Feedback:
Respiratory care and other treatment modalities (oxygen, incentive spirometry, chest physiotherapy
[CPT], and oral, inhaled, or IV medications) may be continued at home. Therefore, the nurse needs to
instruct the patient and family in their correct and safe use. The scenario does not indicate the patient
needs help with suctioning, postural drainage, or tracheostomy care.
26. The nurse is performing patient education for a patient who is being discharged on mini-nebulizer
treatments. What information should the nurse prioritize in the patients discharge teaching?
A)
How to count her respirations accurately
B)
How to collect serial sputum samples
C)
How to independently wean herself from treatment
D)
How to perform diaphragmatic breathing
Ans:
D
Feedback:
Diaphragmatic breathing is a helpful technique to prepare for proper use of the small-volume nebulizer.
Patient teaching would not include counting respirations and the patient should not wean herself from
treatment without the involvement of her primary care provider. Serial sputum samples are not normally
necessary.
27. The nurse is caring for a client with an endotracheal tube who is on a ventilator. When assessing the
client, the nurse knows to maintain what cuff pressure to maintain appropriate pressure on the tracheal
wall?
A)
Between 10 and 15 mm Hg
B)
Between 15 and 20 mm Hg
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C)
Between 20 and 25 mm Hg
D)
Between 25 and 30 mm Hg
Ans:
B
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Feedback:
Complications can occur from pressure exerted by the cuff on the tracheal wall. Cuff pressures should be
maintained between 15 and 20 mm Hg.
28. The decision has been made to discharge a ventilator-dependent patient home. The nurse is developing a
teaching plan for this patient and his family. What would be most important to include in this teaching
plan?
A)
Administration of inhaled corticosteroids
B)
Assessment of neurologic status
C)
Turning and coughing
D)
Signs of pulmonary infection
Ans:
D
Feedback:
The nurse teaches the patient and family about the ventilator, suctioning, tracheostomy care, signs of
pulmonary infection, cuff inflation and deflation, and assessment of vital signs. Neurologic assessment
and turning and coughing are less important than signs and symptoms of infection. Inhaled
corticosteroids may or may not be prescribed.
29. The nurse has explained to the patient that after his thoracotomy, it will be important to adhere to a
coughing schedule. The patient is concerned about being in too much pain to be able to cough. What
would be an appropriate nursing intervention for this client?
A)
Teach him postural drainage.
B)
Teach him how to perform huffing.
C)
Teach him to use a mini-nebulizer.
D)
Teach him how to use a metered dose inhaler.
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B
Feedback:
The technique of huffing may be helpful for the patient with diminished expiratory flow rates or for the
patient who refuses to cough because of severe pain. Huffing is the expulsion of air through an open
glottis. Inhalers, nebulizers, and postural drainage are not substitutes for performing coughing exercises.
30. 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)
Post thoracotomy
B)
Spontaneous pneumothorax
C)
Need for postural drainage
D)
Chest trauma resulting in pneumothorax
E)
Pleurisy
Ans:
A, B, D
Feedback:
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.
31. 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?
A)
Resumption of the patients ADLs
B)
The familys willingness to care for the patient
C)
Nutritional status and fluid balance
D)
Signs and symptoms of respiratory complications
Ans:
D
Feedback:
The nurse assesses the patients adherence to the postoperative treatment plan and identifies acute or late
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postoperative complications. All options presented need assessment, but respiratory complications are
the highest priority because they affect the patients airway and breathing.
32. A patient has been discharged home after thoracic surgery. The home care nurse performs the initial visit
and finds the patient discouraged and saddened. The client states, I am recovering so slowly. I really
thought I would be better by now. What nursing action should the nurse prioritize?
A)
Provide emotional support to the patient and family.
B)
Schedule a visit to the patients primary physician within 24 hours.
C)
Notify the physician that the patient needs a referral to a psychiatrist.
D)
Place a referral for a social worker to visit the patient.
Ans:
A
Feedback:
The recovery process may take longer than the patient had expected, and providing support to the patient
is an important task for the home care nurse. It is not necessary, based on this scenario, to schedule a
visit with the physician within 24 hours, or to get a referral to a psychiatrist or a social worker.
33. A patient is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching
includes what?
A)
Correct use of a ventilator
B)
Correct use of incentive spirometry
C)
Correct use of a mini-nebulizer
D)
Correct technique for rhythmic breathing
Ans:
B
Feedback:
Instruction in the use of incentive spirometry begins before surgery to familiarize the patient with its
correct use. You do not teach a patient the use of a ventilator; you explain that he may be on a ventilator
to help him breathe. Rhythmic breathing and mini-nebulizers are unnecessary.
34. A patient in the ICU has had an endotracheal tube in place for 3 weeks. The physician has ordered that a
tracheostomy tube be placed. The patients family wants to know why the endotracheal tube cannot be
left in place. What would be the nurses best response?
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A)
The physician may feel that mechanical ventilation will have to be used long-term.
B)
Long-term use of an endotracheal tube diminishes the normal breathing reflex.
C)
When an endotracheal tube is left in too long it can damage the lining of the windpipe.
D)
It is much harder to breathe through an endotracheal tube than a tracheostomy.
Ans:
C
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Feedback:
Endotracheal intubation may be used for no longer than 2 to 3 weeks, by which time a tracheostomy
must be considered to decrease irritation of and, trauma to, the tracheal lining, to reduce the incidence of
vocal cord paralysis (secondary to laryngeal nerve damage), and to decrease the work of breathing. The
need for long-term ventilation would not be the primary rationale for this change in treatment.
Endotracheal tubes do not diminish the breathing reflex.
35. The home care nurse is planning to begin breathing retraining exercises with a client newly admitted to
the home health service. The home care nurse knows that breathing retraining is especially indicated if
the patient has what diagnosis?
A)
Asthma
B)
Pneumonia
C)
Lung cancer
D)
COPD
Ans:
D
Feedback:
Breathing retraining is especially indicated in patients with COPD and dyspnea. Breathing retraining
may be indicated in patients with other lung pathologies, but not to the extent indicated in patients with
COPD.
36. The nurse is performing nasotracheal suctioning on a medical patient and obtains copious amounts of
secretions from the patients airway, even after inserting and withdrawing the catheter several times.
How should the nurse proceed?
A)
Continue suctioning the patient until no more secretions are obtained.
B)
Perform chest physiotherapy rather than nasotracheal suctioning.
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C)
Wait several minutes and then repeat suctioning.
D)
Perform postural drainage and then repeat suctioning.
Ans:
C
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Feedback:
If additional suctioning is needed, the nurse should withdraw the catheter to the back of the pharynx,
reassure the patient, and oxygenate for several minutes before resuming suctioning. Chest physiotherapy
and postural drainage are not necessarily indicated.
37. 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?
A)
Determine whether the patient can now perform forced expiratory technique (FET).
B)
Percuss the patients lungs and thorax.
C)
Measure the patients oxygen saturation.
D)
Have the patient perform incentive spirometry.
Ans:
C
Feedback:
The patients response to suctioning is usually determined by performing chest auscultation and by
measuring the patients oxygen saturation. FET, incentive spirometry, and percussion are not normally
used as evaluative techniques.
38. Postural drainage has been ordered for a patient who is having difficulty mobilizing her bronchial
secretions. Before repositioning the patient and beginning treatment, the nurse should perform what
health assessment?
A)
Chest auscultation
B)
Pulmonary function testing
C)
Chest percussion
D)
Thoracic palpation
Ans:
A
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Feedback:
Chest auscultation should be performed before and after postural drainage in order to evaluate the
effectiveness of the therapy. Percussion and palpation are less likely to provide clinically meaningful
data for the nurse. PFTs are normally beyond the scope of the nurse and are not necessary immediately
before postural drainage.
39. A nurse is teaching a patient how to perform flow type incentive spirometry prior to his scheduled
thoracic surgery. What instruction should the nurse provide to the patient?
A)
Hold the spirometer at your lips and breathe in and out like you normally would.
B)
When youre ready, blow hard into the spirometer for as long as you can.
C)
Take a deep breath and then blow short, forceful breaths into the spirometer.
D)
Breathe in deeply through the spirometer, hold your breath briefly, and then exhale.
Ans:
D
Feedback:
The patient should be taught to lace the mouthpiece of the spirometer firmly in the mouth, breathe air in
through the mouth, and hold the breath at the end of inspiration for about 3 seconds. The patient should
then exhale slowly through the mouthpiece.
40. 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 patients
respirations. How should the nurse best respond to this assessment finding?
A)
Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes.
B)
Inform the physician promptly that there is in imminent leak in the drainage system.
C)
Encourage the patient to do deep breathing and coughing exercises.
D)
Document that the chest drainage system is operating as it is intended.
Ans:
D
Feedback:
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.
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Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
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