nclex 6 respiratory
Study online at https://quizlet.com/_4hugf2
1. A client is being pre- 4. Lying in bed on the unaffected side, with the
pared for a thoracen- head of the bed elevated 45 degrees
tesis. The nurse should
assist the client to which
Rationale:
position for the proce- To facilitate the removal of fluid from the chest,
dure? the client is positioned sitting on the edge of the
bed, leaning over a bedside table, with the feet
1. Sims' position, with supported on a stool or lying in bed on the unaf-
the head of the bed flat fected side, with the head of the bed elevated 45
degrees (Fowler's position). Options 1, 2, and 3
2. Prone, with the head are incorrect.
turned to the side sup-
ported by a pillow
3. Lying in bed on the
affected side, with the
head of the bed elevated
45 degrees
4. Lying in bed on the
unaffected side, with the
head of the bed elevated
45 degrees
2. The nurse is provid- 4. Discontinue suctioning until the client is stabi-
ing endotracheal suc- lized and monitor vital signs.
tioning to a client who
is mechanically venti- Rationale:
lated when the client If a client becomes cyanotic or restless or de-
becomes restless and velops tachycardia, bradycardia, or another ab-
tachycardic. Which ac- normal heart rhythm, the nurse must discontin-
tion should the nurse ue suctioning until the client is stabilized. The
take? nurse would also notify the registered nurse. It is
also important to monitor the vital signs and the
1. Notify the Rapid Re- pulse oximetry. If the client's condition continues
sponse Team. to deteriorate, then the respiratory department
and health care provider may need to be notified.
2. Finish the suctioning There is no data in the question that indicates that
as quickly as possible. the rapid response team needs to be notified.
, nclex 6 respiratory
Study online at https://quizlet.com/_4hugf2
3. Contact the respira-
tory department to suc-
tion the client.
4. Discontinue suction-
ing until the client is sta-
bilized and monitor vital
signs.
3. The nurse is as- 3. 50 mL of drainage in the drainage-collection
sisting with monitor- chamber
ing the functioning of
a chest-tube drainage 4. The drainage system is maintained below the
system in a client client's chest.
who just returned from
the recovery room af- 5. An occlusive dressing is in place over the
ter a thoracotomy with chest-tube insertion site.
wedge resection. Which
findings should the 6. Fluctuation of water in the tube of the wa-
nurse expect to note? ter-seal chamber during inhalation and exhalation
Select all that apply.
Rationale:
1. Excessive bubbling in The bubbling of water in the water-seal chamber
the water-seal chamber indicates air drainage from the client. This is usu-
ally seen when intrathoracic pressure is greater
2. Vigorous bubbling than atmospheric pressure, and it may occur dur-
in the suction-control ing exhalation, coughing, or sneezing. Excessive
chamber bubbling in the water-seal chamber may indicate
an air leak, which is an unexpected finding. The
3. 50 mL of drainage fluctuation of water in the tube in the water-seal
in the drainage-collec- chamber during inhalation and exhalation is ex-
tion chamber pected. An absence of fluctuation may indicate
that the chest tube is obstructed, the lung has re-
4. The drainage system expanded, or no more air is leaking into the pleur-
is maintained below the al space. Gentle (not vigorous) bubbling should
client's chest. be noted in the suction-control chamber. A total
of 50 mL of drainage is not excessive in a client
5. An occlusive dress- returning to the nursing unit from the recovery
, nclex 6 respiratory
Study online at https://quizlet.com/_4hugf2
ing is in place over room; however, drainage of more than 70 to 100
the chest-tube insertion mL/hour is considered excessive and requires
site. registered nurse and health care provider notifi-
cation. The chest-tube insertion site is covered
6. Fluctuation of wa- with an occlusive (airtight) dressing to prevent air
ter in the tube of the from entering the pleural space. Positioning the
water-seal chamber dur- drainage system below the client's chest allows
ing inhalation and exha- gravity to drain the pleural space.
lation
4. The nurse is assigned to 3. Continue to monitor, because this is an expect-
assist with caring for a ed finding.
client who has a chest
tube. The nurse notes Rationale:
fluctuations of the flu-The presence of fluctuations in the fluid level in the
id level in the water-seal
water-seal chamber indicates a patent drainage
chamber. Based on this system. With normal breathing, the water level
observation, which ac- rises with inspiration and falls with expiration. The
tion would be appropri- apparatus and all connections must remain air-
ate? tight at all times, and the drainage is never emp-
tied because of the risk of disruption in the closed
1. Empty the drainage. system, which can result in lung collapse. Encour-
aging the client to deep breathe is unrelated to
2. Encourage the client this observation. The client is not told to hold his
to deep breathe. or her breath.
3. Continue to monitor,
because this is an ex-
pected finding.
4. Encourage the client
to hold his or her breath
periodically.
5. The nurse is assigned 4. Perform Valsalva's maneuver.
to assist the health care
provider with the re- Rationale:
moval of a chest tube. When the chest tube is removed, the client is
The nurse should re- asked to perform Valsalva's maneuver (i.e., take
, nclex 6 respiratory
Study online at https://quizlet.com/_4hugf2
inforce instructing the a deep breath, exhale, and bear down), the tube
client to do which during is quickly withdrawn, and an airtight dressing is
this process? taped in place. An alternative instruction is to ask
the client to take a deep breath and hold the
1. Stay very still. breath while the tube is removed. Options 1, 2,
and 3 are incorrect client instructions.
2. Exhale forcefully.
3. Inhale and exhale
quickly.
4. Perform Valsalva's
maneuver.
6. The nurse is assisting in 2. Be sure all connections remain airtight.
planning care for a client
with a chest tube. The 3. Be sure all connections are taped and secure.
nurse should suggest to
include which interven- 5. Monitor closely for tubing that is kinked or ob-
tions in the plan? Select structed by the weight of the client.
all that apply.
Rationale:
1. Pin the tubing to the Chest-tube tubing is never pinned to the bed
bed linens. linens because this presents the risk of accidental
dislodgment of the tube when the client moves.
2. Be sure all connec- The chest tube system is not opened and emptied
tions remain airtight. because a closed system must be maintained; if
the system is opened, lung collapse can occur.
3. Be sure all connec- Options 2, 3, and 5 are appropriate interventions
tions are taped and se- for the plan of care for a client with a chest tube.
cure.
4. Empty the drainage
from the drainage col-
lection chamber daily.
5. Monitor closely for
tubing that is kinked
Study online at https://quizlet.com/_4hugf2
1. A client is being pre- 4. Lying in bed on the unaffected side, with the
pared for a thoracen- head of the bed elevated 45 degrees
tesis. The nurse should
assist the client to which
Rationale:
position for the proce- To facilitate the removal of fluid from the chest,
dure? the client is positioned sitting on the edge of the
bed, leaning over a bedside table, with the feet
1. Sims' position, with supported on a stool or lying in bed on the unaf-
the head of the bed flat fected side, with the head of the bed elevated 45
degrees (Fowler's position). Options 1, 2, and 3
2. Prone, with the head are incorrect.
turned to the side sup-
ported by a pillow
3. Lying in bed on the
affected side, with the
head of the bed elevated
45 degrees
4. Lying in bed on the
unaffected side, with the
head of the bed elevated
45 degrees
2. The nurse is provid- 4. Discontinue suctioning until the client is stabi-
ing endotracheal suc- lized and monitor vital signs.
tioning to a client who
is mechanically venti- Rationale:
lated when the client If a client becomes cyanotic or restless or de-
becomes restless and velops tachycardia, bradycardia, or another ab-
tachycardic. Which ac- normal heart rhythm, the nurse must discontin-
tion should the nurse ue suctioning until the client is stabilized. The
take? nurse would also notify the registered nurse. It is
also important to monitor the vital signs and the
1. Notify the Rapid Re- pulse oximetry. If the client's condition continues
sponse Team. to deteriorate, then the respiratory department
and health care provider may need to be notified.
2. Finish the suctioning There is no data in the question that indicates that
as quickly as possible. the rapid response team needs to be notified.
, nclex 6 respiratory
Study online at https://quizlet.com/_4hugf2
3. Contact the respira-
tory department to suc-
tion the client.
4. Discontinue suction-
ing until the client is sta-
bilized and monitor vital
signs.
3. The nurse is as- 3. 50 mL of drainage in the drainage-collection
sisting with monitor- chamber
ing the functioning of
a chest-tube drainage 4. The drainage system is maintained below the
system in a client client's chest.
who just returned from
the recovery room af- 5. An occlusive dressing is in place over the
ter a thoracotomy with chest-tube insertion site.
wedge resection. Which
findings should the 6. Fluctuation of water in the tube of the wa-
nurse expect to note? ter-seal chamber during inhalation and exhalation
Select all that apply.
Rationale:
1. Excessive bubbling in The bubbling of water in the water-seal chamber
the water-seal chamber indicates air drainage from the client. This is usu-
ally seen when intrathoracic pressure is greater
2. Vigorous bubbling than atmospheric pressure, and it may occur dur-
in the suction-control ing exhalation, coughing, or sneezing. Excessive
chamber bubbling in the water-seal chamber may indicate
an air leak, which is an unexpected finding. The
3. 50 mL of drainage fluctuation of water in the tube in the water-seal
in the drainage-collec- chamber during inhalation and exhalation is ex-
tion chamber pected. An absence of fluctuation may indicate
that the chest tube is obstructed, the lung has re-
4. The drainage system expanded, or no more air is leaking into the pleur-
is maintained below the al space. Gentle (not vigorous) bubbling should
client's chest. be noted in the suction-control chamber. A total
of 50 mL of drainage is not excessive in a client
5. An occlusive dress- returning to the nursing unit from the recovery
, nclex 6 respiratory
Study online at https://quizlet.com/_4hugf2
ing is in place over room; however, drainage of more than 70 to 100
the chest-tube insertion mL/hour is considered excessive and requires
site. registered nurse and health care provider notifi-
cation. The chest-tube insertion site is covered
6. Fluctuation of wa- with an occlusive (airtight) dressing to prevent air
ter in the tube of the from entering the pleural space. Positioning the
water-seal chamber dur- drainage system below the client's chest allows
ing inhalation and exha- gravity to drain the pleural space.
lation
4. The nurse is assigned to 3. Continue to monitor, because this is an expect-
assist with caring for a ed finding.
client who has a chest
tube. The nurse notes Rationale:
fluctuations of the flu-The presence of fluctuations in the fluid level in the
id level in the water-seal
water-seal chamber indicates a patent drainage
chamber. Based on this system. With normal breathing, the water level
observation, which ac- rises with inspiration and falls with expiration. The
tion would be appropri- apparatus and all connections must remain air-
ate? tight at all times, and the drainage is never emp-
tied because of the risk of disruption in the closed
1. Empty the drainage. system, which can result in lung collapse. Encour-
aging the client to deep breathe is unrelated to
2. Encourage the client this observation. The client is not told to hold his
to deep breathe. or her breath.
3. Continue to monitor,
because this is an ex-
pected finding.
4. Encourage the client
to hold his or her breath
periodically.
5. The nurse is assigned 4. Perform Valsalva's maneuver.
to assist the health care
provider with the re- Rationale:
moval of a chest tube. When the chest tube is removed, the client is
The nurse should re- asked to perform Valsalva's maneuver (i.e., take
, nclex 6 respiratory
Study online at https://quizlet.com/_4hugf2
inforce instructing the a deep breath, exhale, and bear down), the tube
client to do which during is quickly withdrawn, and an airtight dressing is
this process? taped in place. An alternative instruction is to ask
the client to take a deep breath and hold the
1. Stay very still. breath while the tube is removed. Options 1, 2,
and 3 are incorrect client instructions.
2. Exhale forcefully.
3. Inhale and exhale
quickly.
4. Perform Valsalva's
maneuver.
6. The nurse is assisting in 2. Be sure all connections remain airtight.
planning care for a client
with a chest tube. The 3. Be sure all connections are taped and secure.
nurse should suggest to
include which interven- 5. Monitor closely for tubing that is kinked or ob-
tions in the plan? Select structed by the weight of the client.
all that apply.
Rationale:
1. Pin the tubing to the Chest-tube tubing is never pinned to the bed
bed linens. linens because this presents the risk of accidental
dislodgment of the tube when the client moves.
2. Be sure all connec- The chest tube system is not opened and emptied
tions remain airtight. because a closed system must be maintained; if
the system is opened, lung collapse can occur.
3. Be sure all connec- Options 2, 3, and 5 are appropriate interventions
tions are taped and se- for the plan of care for a client with a chest tube.
cure.
4. Empty the drainage
from the drainage col-
lection chamber daily.
5. Monitor closely for
tubing that is kinked
