ATI RESPIRATORY

ATI RESPIRATORY A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take? A. Position the client in an upright position, leaning over the bedside table B. Explain the procedure to the client C. Obtain ABGs from the client D. Administer benzocaine pray to the client A A nurse is assessing a client following a bronchoscopy. Which of the following findings should the nurse report to the provider? A. Blood-tinged sputum B. Dry, nonproductive cough C. Sore throat D. Bronchospasms D. Bronchospasms can indicate the client is having difficulty maintaining a patent airway. The nurse should notify the provider immediately A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure is in the client's room? (Select all that apply) A. oxygen equipment B. Incentive spirometer C. Pulse oximeter D. Sterile dressing E. Suture removal kit A, C, D Oxygen equipment is necessary to have in the client's room if the client becomes short of breath following the procedure Pulse oximetry is necessary to monitor the client's oxygen saturation level during the procedure A sterile dressing is necessary to apply to the puncture site following the procedure A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risks for complications? (Select all that apply) A. Dysnea B. Localized bloody drainage on the dressing C. Fever D. Hypotension E. Report of pain at the punture site A, C, D Dyspnea can indicate a pneumothorax or a reaccumulation of fluid. The nurse should notify the provider immediately Fever can indicate an infection. The nurse should notify the provider immediately Hypotension can indicate intrathoracic bleeding. The nurse should notify the provider immediately tidaling expected in water seal chamber cessation of tidaling in water seal chamber signals lung re expansion or an obstructoin within system continuous bubbling in the water seal chamber indicated an air leak pneumothorax air in pleural space hemothorax blood in pleural space pulmonary empyema accumulation of pus chest tube report drainage over 70ml/hr Upgrade to remove ads Only $2.99/month if tubing seperates instruct client to exhale and cough if chest tube drainage system is compromised immerese end of chest tube in sterile water if ac chest tube is accidentally removed dress the area with dry sterile gauze ss tension pneumothorax tracheal deviation absent breath sounds distended neck veins resp distress asymmetry of chest cyanosis A nurse preparing to care for a client following chest tube placement. Which of the following items should be available 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 A, B, C, E Oxygen should be readily available in case the client develops respiratory distress following chest tube placement. If the chest tube becomes disconnected, the end of the tubing should be placed in sterile water to restore the water seal Hemostat clamps should be available for the nurse to use to check air leaks Immediately place an occlusive dressing over the chest tube insertion site if becomes disconnected. This allows air to escape and reduces the risk for a tension pneumothorax A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the client's chest tube was accidentally removed. Which of the following actions should the nurse take first? A. Place the tubing in sterile water to restore the water seal B. Apply sterile gauze to the insertion site C. Place tape around the insertion site D. Assess the client's respiratory status B. Using ABC priority framework, the application of a sterile gauze to the site should be the first action for the nurse to take. This allows the air to escape and reduces the risk of the tension pneumothorax A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (Select all that apply) A. Continuous bubbling in the water seal chamber B. Gentle constant bubbling in the suction control chamber C. Rise and fall in the level of water in the water seal chamber with inspiration D. Exposed sutures without dressing E. Drainage system upright at chest level B, C Gentle bubbling in the suction control chamber is an expected finding as air is being removed A rise and fall of the fluid level in the water seal chamber upon inspiration and expiration indicate that the drainage system is functioning properly 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 B. Use the incentive spirometer C. Cough at regular intervals D. Perform the Valsalva maneuver D. The client should be instructed to take a deep breath, exhale, and bear down as the chest tube is being removed. This increases intrathoracic pressure and reduces the risk of an air embolism A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? (Select all that apply) A. Encourage the client to cough every 2 hours B Check for continuous bubbling in the suction chamber C. Strip the drainage tubing every 4 hours D. Clamp the tube once a day E. Obtain a chest x ray A, B, E Cough every 2 hours to promote oxygenation and lung reexpansion Check for continuous bubbling in the suction chamber to verify that suction is being maintained at an appropriate level A chest x ray is obtained following the procedure to verify chest tube placement O2 mask delivers highest o2 concentration