Question 1 of 9
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The nurse is caring for a patient immediately after a video-assisted thoracoscopic surgery (VATS) procedure. Which nursing intervention is appropriate for this patient?
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- Position patient on unaffected side.The patient should not be placed on the unaffected side because this can diminish the expansion of the good lung.
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- Maintain strict bedrest for first 24 hours.Patients should ambulate as soon as possible (usually within 4–6 hours) after a VATS procedure.
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- Administer pain medication as ordered.Pain management is essential to promote early mobility and adequate breathing.
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- Pin the chest tube tubing to the bedsheets.The chest tube tubing should not be pinned to the bedsheets because it may put tension on the insertion site.
Question 2 of 9
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The nurse is caring for a patient with a chest tube. Which observation would require immediate intervention by the nurse?
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- Occasional bubbling is noted in the water seal chamber.Occasional bubbling in the water seal chamber is expected with breathing, sneezing, or coughing. If continuous bubbling was noted, this indicates an air leak and warrants immediate intervention by the nurse.
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- The drainage system is placed above the patient’s chest level.The nurse should intervene in this situation because the drainage system must be kept below the patient’s chest level to promote drainage by gravity.
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- Connections on the chest tube tubing are wrapped with foam tape.The chest tube apparatus and connections must remain airtight at all times, so the connections should be taped.
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- The night shift nurse changes the entire unit when the collection chamber gets full.The system must remain closed so the entire unit should be changed when it is full instead of emptying the collection chamber.
Question 3 of 9
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The nurse is caring for a postoperative video-assisted thoracoscopic surgery (VATS) patient with a chest tube. Upon assessment, the nurse notices that the chest tube has come unattached from the drainage system. Which is the priority action by the nurse?
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- Call the provider immediately.The provider should be notified, but this is not the priority action at this time.
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- Auscultate the patient’s lungs.The nurse should auscultate the patient’s lungs, but the tubing should be placed in sterile water first to limit the risk of complications.
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- Administer oxygen via nasal cannula.The patient may require oxygen, but this is not the priority intervention at this time.
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- Place the end of the tubing in a container of sterile water.The end of the tubing should be placed in sterile water to form a “water seal” and prevent tension pneumothorax.
Question 4 of 9
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Which intervention would the nurse anticipate when caring for a patient prescribed oral corticosteroids for chronic obstructive pulmonary disease (COPD)?
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- Monitor closely for hypoglycemia.Corticosteroids can increase blood glucose levels, so the nurse would monitor the patient closely for hyperglycemia.
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- Educate patient to avoid potassium in the diet.Oral corticosteroids can cause potassium loss, so it is important for the patient to consume potassium in the diet or supplements.
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- Assess patient often for signs and symptoms of infection.Corticosteroids can blunt the inflammatory response normally seen in early infection, so it is important for the nurse to monitor the patient closely for signs of infection.
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- Allow patient to discontinue taking the medication if feeling better.Corticosteroids must be tapered slowly, so the patient should not abruptly stop taking them, even if feeling better.
Question 5 of 9
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Which patient statement indicates understanding of pursed-lip breathing exercises?
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- “I should lie down while doing these exercises.”Patients should be sitting up when practicing pursed-lip breathing.
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- “I will be sure to hold my breath during exertion.”Patients should be instructed not to hold their breath during exertion and physical activity because this limits gas exchange.
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- “I need to keep my cheeks from puffing out when breathing.”During pursed-lip breathing, patients should be instructed to avoid puffing out their cheeks for proper technique.
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- “I will keep one hand on my belly as I am doing these exercises.”The patient keeps one hand on their abdomen during abdominal (diaphragmatic) breathing.
Question 6 of 9
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Which nursing action is appropriate when caring for a patient receiving oxygen therapy with a partial nonrebreather mask?
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- Make sure the nasal prongs are patent.Nasal prongs are not present with nonrebreather masks. Prongs should be checked for patency with nasal cannulas.
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- Administer high humidity to prevent dryness.Nonrebreather masks cannot be used with high humidity.
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- Limit the oxygen level to a maximum of 6 liters.Nasal cannulas should be limited to a maximum of 6 liters of oxygen. Nonrebreather masks can administer 10 to 20 liters/minute of oxygen.
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- Ensure the bag does not deflate during inspiration.The flow of oxygen to the nonrebreather mask should be high enough that the bag does not deflate with inspiration.
Question 7 of 9
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The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) that is prescribed therapy with 60% oxygen. Which method of oxygen delivery is most appropriate for this patient?
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- Venturi maskVenturi masks are good for delivering low, constant oxygen concentrations to patients with COPD. The concentration and liter flow of this apparatus is available for 60% oxygen.
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- Nasal cannulaNasal cannulas are only able to deliver up to 44% oxygen.
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- Simple face maskSimple face masks can only deliver up to 50% oxygen.
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- Partial nonrebreather maskPartial nonrebreather masks are used to deliver higher concentrations of oxygen between 80% and 90%.
Question 8 of 9
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The nurse is caring for a patient that is intubated and on a ventilator. Which nursing intervention is appropriate for this patient?
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- Avoiding enteral feeding to prevent aspirationContinuous enteral feeding is often initiated for patients on the ventilator to prevent malnutrition.
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- Providing pencil and paper for communicationBecause intubated patients cannot talk, it is important for the nurse to provide other means of communication.
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- Using clean technique while suctioning secretionsAseptic technique should be used when suctioning the ventilator to prevent infection.
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- Turning off the ventilator alarm when suctioning the patientVentilator alarms should never be turned off, even briefly for suctioning because there is a chance they will not be reactivated.
Question 9 of 9
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Which nursing intervention is important in the prevention of ventilator-associated pneumonia (VAP)? Select all that apply. One, some, or all responses may be correct.
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- Digestive decontaminationSelective oral or digestive decontamination should be initiated to prevent VAP.
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- Oral care with chlorhexidineRegular oral care with chlorhexidine has been shown to decrease the risk for VAP.
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- Subglottic secretion suctioningContinuous removal of subglottic secretions should be implemented to prevent VAP.
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- Changing ventilator circuit once dailyThe ventilator circuit should only be changed if visibly soiled or malfunctioning to prevent infection.
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- Administration of prophylactic probioticsProphylactic probiotics should be administered to decrease the risk for VAP.
