Lab practice questions trach/suctioning & chest tube – Flashcards
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Which of the following are indications that a nurse should suction a client? (select all that apply) a. visualization of secretions b. SPO2 greater than 95% c. tachypnea d. Spontaneous cough e. Cyanosis
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a. visualization of secretions c. tachypnea e. Cyanosis
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A nurse is caring for a client who has secretions in the airway. Which of the following is the most effective method for clearing secretions? a. Nasopharyngeal suction b. Deep breathing and coughing c. Endotracheal suction d. Oropharyngeal suction
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b. Deep breathing and coughing
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A nurse should measure a clients airway depth for nasopharyngeal and nasotracheal suctioning by: a. determining the distance from the nares to the sternum b. determining the distance from the tip of the nose to the earlobe c. determining the distance fromt he corner of the mouth to the earlobe d. inserting the catheter until resistance is met
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b. determining the distance from the tip of the nose to the earlobe
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A nurse is caring for a client who is being admitted following a tracheostomy. What equipment should a nurse make sure is in the room? (select all that apply) a. tongue blade b. suction equipment c. pulse oximeter d. oxygen e. spare tracheostomy
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b. suction equipment c. pulse oximeter d. oxygen e. spare tracheostomy
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A nurse is caring for a client who has a tracheotomy. Which of the following interventions should the nurse include? (select all that apply) a. provide the client with materials for nonverbal communication b. use medical aseptic technique when performing tracheostomy care c. Clean the stoma site with saline d. Change the tracheostomy ties each time tracheostomy care is given e. keep pressure greater than 30 mm Hg
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a. provide the client with materials for nonverbal communication c. Clean the stoma site with saline
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A client has returned to the nursing unit following a tracheostomy. Which of the following assessments should the nurse do first? a. time when client last received pain medication b. Respiratory rate and breath sounds c. amount of oxygen ordered to be delivered d. status of tracheostomy dressing
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b. Respiratory rate and breath sounds
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The patient returns fromt he operating room and the nurse assesses for subcutaneous emphysema which is a potential complication associated with tracheostomy. How does the nurse assess for this commplication? a. Inspecting and palpating for air under the skin b. assessing the tube for patency c. listening for airwaflow through the tube d. checking the coulme of the pilot balloon
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a. Inspecting and palpating for air under the skin
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To prevent accidental decannulation of a tracheostomy tube, what does thenurse do? a. secure the tube inplace using ties or fabric fasteners b. Obtain an order for continuous upper extremity restraints c. Instruct the patient to hold the tube with a tissue while coughing d. allows some flexibility in motion of the tube while coughing
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a. secure the tube inplace using ties or fabric fasteners
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The patient has a recent tracheosotmy. What necessary equipment does the nurse ensure is kept at the bedside? a. pair of wire cutters b. tracheostomy tube with obturator c. ambu bag and oxygen tubing d. pocket mask and code cart
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b. tracheostomy tube with obturator
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The patient with a tracheostomy tube is currently alert and cooperative but seems to be coughing more frequently and producing more secretions than usual. The nurse determines that there is a need for suctioning. Which nursing interventions does the nurse use to prevent hypoxia for this patient? a. avoid prolonged suctioning time b. use the largest available catheter c. Allow the patient to breathe room air prior to suctioning d. suction frequently when the patient is coughing
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a. avoid prolonged suctioning time
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While changing the tapes on a tracheostomy tube, the male client coughs and the tube is dislodged. The initial nursing action is to: a. Call the physician to reinsert the tube. b. Grasp the retention sutures to spread the opening. c. Call the respiratory therapy department to reinsert the tracheotomy. d. Cover the tracheostomy site with a sterile dressing to prevent infection.
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b. Grasp the retention sutures to spread the opening.
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How do you know if there is an airleak in the chest tube?
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bubbling in the water seal chamber
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After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must: a) report fluctuations in the water-seal chamber. b) clamp the chest tube once every shift. c) encourage coughing and deep breathing. d) milk the chest tube every 2 hours.
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c) encourage coughing and deep breathing.
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The nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is: a) helping him communicate. b) keeping his airway patent. c) encouraging him to perform activities of daily living. d) preventing him from developing an infection.
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b) keeping his airway patent.
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While changing soiled velcro ties for a client with a tracheostomy, the client suddenly coughs, dislodging a tracheostomy tube. Which of the following is the appropriate nursing action? a. Provide ventilation with a manual resuscitation bag and face mask. b. Have a coworker call the emergency response team. c. Reinsert the tracheostomy tube. d. Cover the tracheostomy opening with a sterile dressing.
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c. Reinsert the tracheostomy tube.
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A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following indicates that the nurse should suction the client's airway secretions? a. The client is unable to speak. b. The client's airway secretions were last suctioned 2 hr ago. c. The client coughs and expectorates a large mucous plug. d. The nurse auscultates coarse crackles in the lung fields.
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d. The nurse auscultates coarse crackles in the lung fields.
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A nurse is caring for a client who is being admitted following a tracheotomy. What equipment should a nurse make sure is in the room?
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Humidified oxygen Pulse oximeter Suction equipment and catheters Spare tracheostomy tube Extra tracheostomy ties Normal saline Split 4x4 dressings
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A nurse is suctioning fluids from a male client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of: ______ seconds
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10
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While observing a client who is unconscious following major trauma, the nurse notes that a portion of the client's chest pulls inward on inspiration. On expiration, the same portion expands outward. The nurse documents the presence of which of the following? a. Symmetrical chest movement. b. Intercostal retractions. c. Flail chest. d. Cheyne-Stokes respirations
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c. Flail chest.
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When should you apply suction to a tracheostomy?
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upon withdrawal, not while inserting
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A patient with respiratory failure has a respiratory rate of 8 and an SpO2 of 89%. The patient is increasingly lethargic. The nurse will anticipate assisting with _______________
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endotracheal intubation and positive pressure ventilation.
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A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family? a) "Clean the tracheostomy tube with alcohol and water." b) "Family members should continue to talk to the client." c) "Oral intake of fluids should be limited for 1 week only." d) "Limit the amount of protein in the diet."
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b) "Family members should continue to talk to the client."
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A nurse is assisting with the care of a client who has a tracheostomy in place. The nurse determines that the client's airway secretions require suctioning after auscultating the lung fields and prepares to apply suction using the open method. Put the following steps in order: 1. Apply suction. 2. Explain the procedure to the client. 3. Increase the flow of oxygen via the tracheostomy collar. 4. Insert the suction catheter into the tracheostomy.
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2. Explain the procedure to the client. 3. Increase the flow of oxygen via the tracheostomy collar. 4. Insert the suction catheter into the tracheostomy. 1. Apply suction.
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A client undergoes a tracheostomy after many failed attempts at weaning him from a mechanical ventilator. Two days after tracheostomy, while the client is being weaned, the nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first? a) Call the physician. b) Remove the malfunctioning cuff. c) Add more air to the cuff. d) Suction the client, withdraw residual air from the cuff, and reinflate it.
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d) Suction the client, withdraw residual air from the cuff, and reinflate it.
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A nurse is suctioning fluids from a male client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of: a. 1 minute b. 5 seconds c. 10 seconds d. 30 seconds
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c. 10 seconds Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.
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The nurse is planning care for a client after a tracheostomy. One of the client's goals is to overcome verbal communication impairment. Which of the following interventions should the nurse include in the care plan? a) Make an effort to read the client's lips to foster communication. b) Encourage the client's communication attempts by allowing him time to select or write words. c) Answer questions for the client to reduce his frustration. d) Avoid using a tracheostomy plug because it blocks the airway.
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b) Encourage the client's communication attempts by allowing him time to select or write words.
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The nurse is caring for a client who has a tracheostomy tube and is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by: a) suctioning the tracheostomy tube frequently. b) using a cuffed tracheostomy tube. c) using the minimal air leak technique with cuff pressure less than 25 cm H2O. d) keeping the tracheostomy tube plugged.
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c) using the minimal air leak technique with cuff pressure less than 25 cm H2O.
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A nurse is caring for a client following a tracheotomy 2 days ago. The nurse enters the room and notices that the tracheostomy tube is no longer in place. Describe the actions the nurse should take.
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Call for assistance Assess respiratory rate/effort/color/Sa02 Obtain obturator and a spare tracheostomy tube and reinsert, if possible
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A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? a) Endotracheal suctioning b) Encouragement of coughing c) Use of cooling blanket d) Incentive spirometry
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a) Endotracheal suctioning
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The nurse caring for a male client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to: a. Call the physician. b. Place the tube in a bottle of sterile water. c. Immediately replace the chest tube system. d. Place the sterile dressing over the disconnection site
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b. Place the tube in a bottle of sterile water.
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How to prevent complications on pt with chest
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avoid dependent loops never raise drainage system above pts chest assess pt and integrity every hr.
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Nurse Kim is caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is appropriate? a. Do nothing, because this is an expected finding. b. Immediately clamp the chest tube and notify the physician. c. Check for an air leak because the bubbling should be intermittent. d. Increase the suction pressure so that bubbling becomes vigorous.
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a. Do nothing, because this is an expected finding.
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What is important to have in a patients room after chest tube insertion? why?
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a pair of padded clamps just in case the chest tube becomes disconnected
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Indications for a chest tube
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Pneumothorax (collapsed lung) Hemothorax (blood in the lung) Postoperative chest drainage (thoracotomy or open heart surgery) Pleural effusion (fluid in the lungs) Lung abscess (necrotic lung tissue)
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When is a chest tube removed?
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when the lungs have reexpanded and/or there is no more fluid drainage
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What are the 3 criteria for removal of chest tube?
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-less than 75 cc/day -reinflation of the lung -decreased symptoms
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What symptoms would a client manifest in order for a nurse to recommend a possible chest tube insertion?
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Dyspnea Distended neck veins Poor circulation Cough
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A nurse is caring for a client transferred from the post anesthesia care unit following a left pneumonectomy for adenocarcinoma. Which type of chest drainage should the nurse anticipate the client will have? a. Bilateral chest tubes b. One chest tube on the operative side c. Two chest tubes on the operative side d. No chest drainage
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d. No chest drainage
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A 47-year-old male client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is: a) lobar pneumonia. b) empyema. c) Pneumocystis carinii pneumonia. d) infected chest tube wound site.
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b) empyema.
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What is considered excess drainage (for a chest tube)?
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>70mL/hr
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A client with a pneumothorax receives a chest tube attached to a Pleur-evac. The nurse notices that the fluid of the second chamber of the Pleur-evac isn't bubbling. Which nursing assumption would be most invalid? a) The tubing from the client to the chamber is blocked. b) There is a leak somewhere in the tubing system. c) The client's affected lung has reexpanded. d) The tubing needs to be cleared of fluid
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b) There is a leak somewhere in the tubing system.
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A nurse has received a client who has had a chest tube placed. While assessing the client, the nurse notices that the client's chest tube has become dislodged. Which of the following actions should the nurse take first? A. Place the tubing into sterile water to restore the water seal. B. Apply sterile gauze to the site. C. Tape or clamp all connections. D. Assess the client's respiratory status.
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B. Apply sterile gauze to the site.
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A client has a sucking stab wound to the chest. Which action should the nurse take first? a) Draw blood for a hematocrit and hemoglobin level. b) Apply a dressing over the wound and tape it on three sides. c) Prepare a chest tube insertion tray. d) Prepare to start an I.V. line.
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b) Apply a dressing over the wound and tape it on three sides.
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A nurse is preparing to recceive a client who has had a chest tube placed. Which of the following items should the nurse have placed in the client's room? (Select all that apply.) a. Oxygen b. Sterile water c. Enclosed hemostat clamps d. Indwelling urinary catheter e. Occlusive dressing f. Suction source g Bladder scan machine
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a. Oxygen b. Sterile water c. Enclosed hemostat clamps e. Occlusive dressing f. Suction source
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A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do? A. Lie on his left side during removal. B. Hold his breath. C. Inhale deeply during removal. D. Perform the Valsalva maneuver during removal.
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D. Perform the Valsalva maneuver during removal.
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A nurse is reviewing a care plan for a client admitted following chest tube placement for a spontaneous pneumothorax. Which of the following interventions should the nurse expect to see? a. Tape all connections between the chest tube and drainage system. b. Keep the water-seal drainage system at the level of the right atrium. c. Notify the provider if there is continuous bubbling in the suction control chamber. d. Empty the collection bottle and record the amount of drainage every 8 hr.
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a. Tape all connections between the chest tube and drainage system.
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Explain a chest tube:
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Inserted into the pleural space to drain fluid, blood, or air; Reestablish a negative pressure; facilitate lung expansion; restore normal intrapleural pressure.
