SS ATI Practice Assessment.N 4581 Answer Key for Airway.CT Mgmt 2021//2022.

SS ATI Practice Assessment.N 4581 Answer Key for Airway.CT Mgmt 2021//2022. A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take? A. Check the tubing connections for leaks. Rationale: This action is used to determine why a water seal chamber has continuous bubbling, not slow, steady bubbling. B. Check the suction control outlet on the wall. Rationale: This action is used to determine why a suction control chamber that is hooked to wall suction has little or no bubbling. C. Clamp the chest tube. Rationale: The nurse should briefly clamp the chest tube to check for air leaks or to change the drainage system. This is not an appropriate action for the nurse to take at this time. D. Continue to monitor the client's respiratory status. Rationale: Slow, steady bubbling in the suction control chamber is an expected finding. Therefore, the nurse should continue to monitor the client's respiratory status. 2. A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first? A. Pain severity Rationale: The nurse should assess the client's pain level to help provide adequate pain management; however, another assessment is the priority. B. Wound drainage Rationale: The nurse should assess the quantity and character of drainage from the surgical wound to monitor for hemorrhage; however, another assessment is the priority. C. Tissue integrity Rationale: Head and neck surgeries often require tissue flaps to close the surgical wound. The nurse should monitor color and capillary refill in the area of the flap(s) to help determine viability; however, another assessment is the priority. D. Airway patency Rationale: When using the airway, breathing, circulation approach to client care, the nurse determines that the priority assessment is airway patency. After head and neck surgery, a major, life-threatening complication is airway obstruction. The priority actions involve airway maintenance and gas exchange. A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take? A. Clamp the chest tube prior to transferring the client to a wheelchair. Rationale: Clamping the tube can lead to a tension pneumothorax (collapse of the lung) due to increased intrathoracic pressure from gas and fluid that cannot be drained from the pleural space. B. Disconnect the chest tube from the drainage system during transport. Rationale: The chest tube should not be disconnected from the drainage system. C. Keep the drainage system below the level of the client's chest at all times. Rationale: During transport, the drainage system should be kept below the level of the client's chest to prevent air and drainage fluid from re-entering the thoracic cavity. D. Empty the collection chamber prior to transport. Rationale: Emptying the collection chamber prior to transport is unnecessary. 4. A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider? A. Movement of the trachea toward the unaffected side Rationale: A chest tube inserted for a spontaneous pneumothorax may result in the development of a tension pneumothorax, a medical emergency. This results from air in the pleural space compressing the blood vessels of the thorax and limiting blood return to the heart. An assessment of tracheal deviation, or movement of the trachea toward the unaffected side, is indicative of tension pneumothorax and should be reported to the provider immediately. B. Bubbling of the water in the water seal chamber with exhalation Rationale: The water seal chamber prevents air from re-entering the pleural space. Bubbling in this chamber indicates air is being removed from the client’s pleural space, allowing re-expansion of the lung. It should occur during exhalation, coughing, and sneezing. When the air from the pleural space is removed, the bubbling will stop. Excessive bubbling in this chamber may indicate an air leak and should be further investigated by the nurse. C. Crepitus in the area above and surrounding the insertion site Rationale: Crepitus, or subcutaneous emphysema, sounds like a crackling noise when palpated. It can be an expected finding in the client who has a pneumothorax and will persist for several hours (or longer, depending on how long it takes the air to be reabsorbed) following evacuation of the pneumothorax. D. Eyelets are not visible Rationale: The observation of eyelets would indicate to the nurse that the chest tube has been become dislodged from the pleural space and would necessitate reporting to the provider A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take? A. Obtain a cardiology consult. Rationale: These manifestations are not related to a cardiac condition in this situation. B. Suction the client less frequently. Rationale: These manifestations are not the result of suctioning too frequently. C. Administer an antidysrhythmic medication. Rationale: These manifestations cannot be corrected with the use of an antidysrhythmic medication. D. Perform pre-oxygenation prior to suctioning. Rationale: Suctioning should be performed on the endotracheal tube of a client who is mechanically ventilated to remove accumulated secretions from the airways. Possible complications of the procedure include hypoxemia, manifested by tachycardia and arrhythmia, and tissue injury. . In preparation for suctioning, and to prevent hypoxemia, the client should be pre-oxygenated using a manual resuscitator bag set at 100% oxygen. 6. A nurse is caring for a client who is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? A. Continue to monitor the client as this is an expected finding. Rationale: The expected finding would be a gentle bubbling of the water in the suction control chamber. B. Add more water to the suction control chamber of the drainage system. Rationale: More water should not be added to the closed system. C. Verify that the suction regulator is on and check the tubing for leaks. Rationale: A lack of bubbling may indicate that either the suction regulator is turned off or that there is a leak in the tubing. D. Milk the chest tube and dislodge any clots in the tubing that are occluding it. Rationale: Stripping, or milking, can pull too hard on the chest cavity and may cause a tissue injury to the lung. Stripping is only done when specifically indicated.