AG2 Respiratory

A nurse providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this situation?

• Call the physician.

• Put on gloves and insert the chest tube in a bottle of sterile saline.

• Apply an occlusive dressing on the site.

• Assess the patient for signs of respiratory distress.

Answer explanation

When a chest tube becomes separated from the drainage device, the nurse should first put on gloves, open a sterile bottle of normal saline or water, and insert the chest tube into the bottle without contaminating the chest tube. This creates a water seal until a new drainage unit can be attached. Then the nurse should assess vital signs and notify the physician.

A nurse is caring for a male client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client?

• Stridor

• Occasional pink-tinged sputum

• A few basilar lung crackles on the right

• Respiratory rate of 24 breaths/min

Answer explanation

Stridor indicates airway edema and places the client at risk for airway obstruction

If a patient is in metabolic acidosis, what might their lab result look like? (Give me their pH, pCO2, and pHCO3; UNCOMPENSATED)

An emergency room nurse is assessing a female client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client?

• A low respiratory

• The presence of a barrel chest

• A sucking sound at the site of injury

• Diminished breathe sounds

Answer explanation

This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.

A nurse is assessing a female client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse assesses for which earliest sign of acute respiratory distress syndrome?

• Bilateral wheezing

• Inspiratory crackles

• Intercostal retractions

• Increased respiratory rate

Answer explanation

The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis.Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.

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?

• The system is functioning normally.

• The patient has a pneumothorax.

• The system has an air leak.

• The chest tube is obstructed.

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 explanation

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.

Which assessment data would support that the client has experienced a pulmonary embolus?

• Calf pain with dorsiflexion of the foot.

• Sudden onset of chest pain and dyspnea.

• Left-sided chest pain and diaphoresis.

• Bilateral crackles and low-grade fever.

Answer explanation

Anxiety ● Feelings of impending doom ● Sudden onset of chest pressure ● Sharp, stabbing chest pain ● Dyspnea and air hunger ● Cough ● Hemoptysis

Match the following

• Hemothorax

• Air in the pleural cavity caused by a puncture of the lung or chest wall

• Tension Pneumothorax

• Hypoxemia persists despite oxygen therapy.

• ARDS

• Trapped air compresses the heart & lung. Death can result if not treated immediately.

• Flail Chest

• At least 2 neighboring ribs, usually on one side of the chest, sustain multiple fractures, causing instability of the chest wall and paradoxical chest wall

• Pneumothorax

• A collection of blood in the pleural cavity.

Your patient, who is on Heparin, just had an ABG blood test drawn. How long are you suppose to hold pressure for?

• 5 minutes

• 10 minutes

• 15 minutes

• 20 minutes

• 30 minutes