3 - The nurse is caring for a client with a chest tube drainage system. The nurse notes a fluctuating water level on inspiration and expiration in the
... [Show More] submerged tube in the water seal chamber of the chest tube drainage system. Which nursing action is appropriate?
1.Suction the client.
2.Increase the suction.
3.Document the findings.
4.Encourage coughing and deep breathing
2 - The nurse is caring for a client with a chest tube drainage system and notes constant bubbling in the water seal chamber. Which nursing action is appropriate?
1.Reposition the client.
2.Notify the health care provider (HCP).
3.Change the chest tube drainage system.
4.No action is necessary because this is a normal, expected finding
4 - A client being mechanically ventilated after experiencing a fat embolism is visibly anxious. What is the best nursing action?
1.Ask a family member to stay with the client at all times.
2.Ask the health care provider for a prescription for succinylcholine.
3.Encourage the client to sleep until arterial blood gas results improve.
4.Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed
1 - client has been treated for pleural effusion with a thoracentesis. The nurse determines that this procedure has been effective if the nurse notes which assessment finding?
1.Absence of dyspnea
2.Increased severity of cough
3.Dull percussion notes over lung tissue
4.Decreased tactile fremitus over lung tissue
2 - The nurse assesses for one-sided chest movement on the right while a client is being intubated by the health care provider. Which could occur with the endotracheal tube?
1.It could enter the left main bronchus if inserted too far.
2.It could enter the right main bronchus if inserted too far.
3.It could enter the left main bronchus if not inserted far enough.
4.It could enter the right main bronchus if not inserted far enough
3 - The nurse is assisting a radiologist to facilitate a thoracentesis. The nurse assists the client to a position that widens the spaces between the ribs to help drain which area?
1.Alveoli
2.Trachea
3.Pleural space
4.Main bronch
4 - The nurse has completed care for a client whose tracheostomy tube has a nondisposable inner cannula. Which action should the nurse perform prior to reinserting the inner cannula?
1.Suction the client's airway.
2.Wipe the inner cannula off with a clean washcloth. 3.Dry the inner cannula thoroughly with sterile gauze. 4.Allow the inner cannula to dry after washing it with sterile water.
2 - The client is returned to the nursing unit following thoracic surgery with a chest tube in place. During the first few hours postoperatively, the nurse assesses for drainage and expects to note which characteristics?
1.The drainage is serous.
2.The drainage is bloody.
3.The drainage is serosanguineous.
4.The drainage is bloody, with frequent small clots
2 - he nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal compartment. Which is the most appropriate action?
1.Check for an air leak.
2.Document the findings.
3.Notify the health care provider (HCP).
4.Change the chest tube drainage system.
2 - A client is on continuous mechanical ventilation (CMV), and the low-pressure alarm sounds. The nurse should take which action?
1.Make sure that the client is not lying on the ventilator tubing.
2.Determine if there are any disconnections in the ventilator tubing.
3.Check to see if the client is biting on the endotracheal tube (ETT).
4.Auscultate the lungs to determine if the client needs to be suctioned.
4 - A client is on continuous mechanical ventilation (CMV) and the high-pressure alarm sounds. Which action should the nurse take to eliminate the problem?
1.Silence the alarm to avoid disturbing the client. 2.Check the ventilator circuit for any disconnections. 3.Inflate the cuff of the endotracheal tube to a pressure of 25 mm Hg.
4.Empty excess accumulated water from the ventilatory circuit tubing
4 - The nurse determines that the client with a chest tube to a closed drainage system is experiencing an air leak. Which finding is indicative of this?
1.Tidaling is absent.
2.Gentle bubbling is observed in the suction control chamber.
3.Vacillation of water in the water seal chamber occurs during respiration.
4.Continuous bubbling is observed in the water seal chamber during inspiration and expiration. [Show Less]