ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 21 : Respiratory Care Modalities Questions
Question 1 of 5
What would the critical care nurse recognize as a condition that may indicate a patients need to have a tracheostomy?
Correct Answer: B
Rationale: 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.
Question 2 of 5
The medical nurse is creating the care plan of an adult patient requiring mechanical ventilation. What nursing action is most appropriate?
Correct Answer: D
Rationale: 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.
Question 3 of 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?
Correct Answer: B
Rationale: 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.
Question 4 of 5
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?
Correct Answer: D
Rationale: 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.
Question 5 of 5
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?
Correct Answer: A
Rationale: 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.