NCLEX Practice Exam for Respiratory System 2

EXPLANATION

✔Correct answer:

A cough producing mucoid sputum. One of the early symptoms of tuberculosis (TB) is a persistent cough that may produce mucoid (clear or whitish) sputum. This occurs as the Mycobacterium tuberculosis infection begins to affect the lungs, causing irritation and inflammation. The cough is often nonproductive initially but may progress over time to include purulent or bloody sputum as the disease advances. Early identification of this symptom is important for prompt diagnosis and treatment, especially in high-risk populations.

At this stage, the cough is usually accompanied by general systemic symptoms such as fatigue, low-grade fever (especially in the afternoon), night sweats, and unintentional weight loss. Recognizing these early signs and referring individuals for diagnostic testing, such as a sputum culture or chest X-ray, is critical in preventing disease progression and community transmission.

Think of the early TB cough like a leaky faucet—it's persistent and mild at first, signaling that something is wrong. Over time, if untreated, the "leak" worsens and causes more noticeable damage (e.g., bloody or purulent sputum).

Education and early detection of TB are essential components of community health nursing. Nurse Karen should emphasize the following during her health class:

• Encourage individuals with persistent coughs lasting more than 2-3 weeks to seek medical evaluation.
• Educate on the systemic symptoms of TB, including night sweats, fever, weight loss, and fatigue.
• Discuss the importance of completing the full course of treatment if diagnosed with TB to prevent drug resistance.
• Stress the role of screening and testing (e.g., Mantoux tuberculin skin test or interferon-gamma release assays) for high-risk groups.
• Provide information about infection control measures, such as wearing masks and isolating active TB cases, to reduce transmission.

✘Incorrect answer options:

Shortness of breath (dyspnea): Dyspnea is usually a late symptom of TB and occurs when the disease has significantly progressed, leading to extensive lung damage or complications such as pleural effusion or pneumothorax.

Discomfort or pain in the chest: Chest pain can occur in TB but is more commonly associated with advanced stages of the disease, particularly when pleuritis or pleural effusion develops.

A bloody and productive cough: Hemoptysis (bloody sputum) is a later-stage symptom of TB, typically occurring when the infection causes erosion of blood vessels or advanced lung tissue destruction.

EXPLANATION

✔Correct answer:

Reduced breath sounds upon auscultation. Reduced or absent breath sounds upon auscultation on the affected side are a hallmark finding of a pneumothorax, a condition where air accumulates in the pleural space and compresses the lung, leading to its partial or complete collapse. When the lung cannot expand fully, breath sounds in that area become diminished or inaudible. This finding is often accompanied by other clinical signs, such as dyspnea, tachypnea, and chest discomfort, depending on the severity of the pneumothorax.

The absence of breath sounds on one side is a key diagnostic clue and warrants further evaluation, such as a chest X-ray, to confirm the diagnosis and determine the extent of lung collapse. Immediate intervention may be required, such as insertion of a chest tube to re-expand the lung.

Think of the lung as a balloon that fills with air when you breathe. If the balloon has a hole or deflates (as with a pneumothorax), you won't hear the sound of air entering or leaving it because it’s not functioning properly.

When pneumothorax is suspected, immediate actions are necessary to ensure accurate diagnosis and timely treatment. These include:

• Conduct a thorough respiratory assessment, including auscultation, inspection, and palpation for tracheal deviation or subcutaneous emphysema.
• Administer oxygen therapy as prescribed to support oxygenation.
• Prepare the patient for diagnostic imaging, such as a chest X-ray, to confirm the pneumothorax.
• Monitor for signs of worsening respiratory distress, such as cyanosis or hypotension, which could indicate a tension pneumothorax.
• Collaborate with the healthcare team for interventions, such as needle decompression or chest tube insertion, if necessary.

✘Incorrect answer options:

A decreased respiratory rate: Pneumothorax typically causes tachypnea (increased respiratory rate) as the body attempts to compensate for impaired oxygenation. A decreased respiratory rate would not be a common finding in pneumothorax unless severe respiratory failure occurs, which would be a late and critical sign.

The appearance of a barrel-shaped chest: A barrel-shaped chest is associated with chronic conditions such as chronic obstructive pulmonary disease (COPD) and is not a characteristic feature of pneumothorax. Pneumothorax is more likely to cause asymmetry of chest expansion during breathing.

A noticeable sucking sound at the injury site: While a sucking sound at the injury site is indicative of an open pneumothorax (also called a "sucking chest wound"), this specific finding is only present when there is a direct, penetrating injury to the chest wall. In a closed pneumothorax from blunt trauma, this sound would not be observed.

EXPLANATION

✔Correct answer:

A faster-than-normal respiratory rate. Tachypnea (a faster-than-normal respiratory rate) is often the earliest indicator of acute respiratory distress syndrome (ARDS). This increase in respiratory rate reflects the body's attempt to compensate for hypoxemia (low oxygen levels) and impaired gas exchange caused by early alveolar damage and fluid accumulation in the lungs. In the initial stages of ARDS, symptoms can be subtle, with tachypnea being the most noticeable clinical finding before more severe signs, such as retractions or crackles, develop.

As ARDS progresses, fluid leaks into the alveoli, causing worsening hypoxemia, decreased lung compliance, and increased work of breathing, which results in more pronounced symptoms like dyspnea, intercostal retractions, and crackles.

Think of ARDS like an engine overheating due to a clogged radiator. At first, the engine fan (tachypnea) runs faster to compensate. This is an early sign that something is wrong, long before steam (crackles or retractions) starts to appear.

Early detection and intervention are critical in ARDS to improve outcomes. The nurse should closely monitor patients at risk, such as those with trauma, sepsis, or aspiration, for early warning signs like tachypnea. Key nursing actions include:

• Monitor respiratory rate and pattern closely for any increases or changes in effort.
• Assess oxygen saturation and arterial blood gases (ABGs) to identify early hypoxemia.
• Report tachypnea and worsening oxygenation to the healthcare provider promptly.
• Provide supplemental oxygen as prescribed to address hypoxemia and reduce respiratory distress.
• Prepare for possible intubation and mechanical ventilation if ARDS progresses.

✘Incorrect answer options:

Wheezing heard bilaterally: Wheezing is not typically associated with ARDS. It is more characteristic of airway obstruction conditions, such as asthma or chronic obstructive pulmonary disease (COPD).

Crackles during inspiration: Crackles (rales) develop later in ARDS as fluid accumulates in the alveoli. They are not typically an early finding and occur as the disease progresses to severe alveolar damage and pulmonary edema.

Visible intercostal retractions: Retractions indicate increased work of breathing and are more likely to appear in the later stages of ARDS when hypoxemia worsens and lung compliance decreases. They are not an early sign.

EXPLANATION

✔Correct answer:

Discontinue suctioning and reoxygenate the patient. A decreasing heart rate during suctioning indicates potential vagal stimulation or hypoxia, both of which can occur as a result of the procedure. Stimulation of the vagus nerve can lead to bradycardia (slowed heart rate), and insufficient oxygenation during suctioning can exacerbate this issue. The correct immediate action is to discontinue suctioning and focus on reoxygenating the patient by providing 100% oxygen. This ensures the patient recovers adequate oxygen levels and prevents further complications.

Once the patient's vital signs stabilize, Nurse Ellen can reassess the need for suctioning, ensuring that it is performed safely and in adherence to appropriate time limits (typically no more than 10-15 seconds per pass).

Think of suctioning like briefly turning off the water supply while repairing a faucet. If you notice the water pressure (oxygen levels) dropping dangerously low, you must quickly restore the water supply (oxygen) before continuing the repair.

To ensure safe suctioning and avoid complications, Nurse Ellen should follow these key steps:

• Stop suctioning immediately if the patient shows signs of bradycardia, hypoxia, or respiratory distress.
• Administer 100% oxygen for 30-60 seconds to reoxygenate the patient and restore oxygen saturation levels.
• Limit each suctioning attempt to 10-15 seconds to minimize hypoxia and vagal stimulation.
• Allow sufficient recovery time between suctioning attempts (30-60 seconds) and monitor vital signs closely.
• Notify the healthcare provider if bradycardia or other complications persist after reoxygenation.

✘Incorrect answer options:

Proceed with the suctioning process: Continuing suctioning when bradycardia is observed could worsen the patient's condition, as the underlying issue (vagal stimulation or hypoxia) would remain unaddressed.

Immediately inform the physician of the change: While notifying the physician is important, it is not the immediate priority. The nurse must first take action to reoxygenate the patient and stabilize vital signs before escalating care if necessary.

Verify that suctioning is limited to 15 seconds: Limiting suctioning duration is a standard practice to prevent complications, but this step does not address the immediate issue of bradycardia during the procedure. Suctioning should be stopped entirely, and the patient should be reoxygenated first.

EXPLANATION

✔Correct answer:

To aid in eliminating carbon dioxide. The primary purpose of pursed-lip breathing is to aid in eliminating carbon dioxide (CO₂) by promoting better airflow and preventing airway collapse during exhalation. Patients with chronic obstructive pulmonary disease (COPD) often experience air trapping due to narrowed airways and reduced lung elasticity. This air trapping leads to the retention of CO₂ and causes difficulty in fully exhaling.

Pursed-lip breathing helps create a slight back-pressure in the airways, keeping them open longer during exhalation and allowing more CO₂ to be expelled. This technique improves gas exchange, reduces dyspnea, and increases the patient’s sense of control over their breathing.

Think of blowing air through a narrow straw. If you purse your lips, the flow slows down, and you have more control over the air leaving. Similarly, pursed-lip breathing slows exhalation and helps release trapped air in the lungs.

Teaching patients how to perform pursed-lip breathing can help them manage their COPD symptoms effectively. Nurse Carla should ensure Mrs. Evans understands and practices the technique correctly:

• Instruct the patient to inhale slowly through the nose for about two counts.
• Encourage the patient to purse their lips as if they are about to whistle.
• Instruct the patient to exhale slowly and gently through the pursed lips for four counts, or twice as long as the inhalation.
• Reassure the patient that this technique can help them feel less short of breath during activities or exacerbations.
• Encourage the patient to practice pursed-lip breathing regularly and incorporate it into daily activities, such as walking or climbing stairs.

✘Incorrect answer options:

To enhance oxygen intake: Pursed-lip breathing does not directly increase oxygen intake. Its primary effect is on improving exhalation and reducing CO₂ retention, which can indirectly improve oxygenation by optimizing gas exchange.

To improve diaphragm strength: Pursed-lip breathing is not designed to strengthen the diaphragm. Diaphragmatic breathing, not pursed-lip breathing, focuses on engaging the diaphragm more effectively.

To build stronger intercostal muscles: Pursed-lip breathing does not target muscle strengthening. It focuses on improving airflow and gas exchange by preventing airway collapse during exhalation.

EXPLANATION

✔Correct answer:

Sudden onset of dyspnea. Sudden onset of dyspnea (shortness of breath) is the most common and classic manifestation of a pulmonary embolism (PE). A PE occurs when a blood clot, usually originating in the deep veins of the legs (deep vein thrombosis), travels to the lungs and obstructs blood flow in the pulmonary arteries. This obstruction impairs oxygen exchange and creates a mismatch between ventilation and perfusion, leading to acute respiratory distress.

Dyspnea in a PE typically arises suddenly and may be accompanied by other symptoms such as pleuritic chest pain, tachycardia, hypoxemia, hemoptysis, or signs of shock in severe cases. These clinical findings require immediate investigation and intervention, as a PE can be life-threatening if untreated.

Think of a pulmonary embolism as a traffic jam in the lungs' blood vessels. The sudden obstruction causes a "backup" in the system, making it harder for oxygen to reach the body, which results in the sudden shortness of breath (dyspnea).

A suspected pulmonary embolism is a medical emergency, and the nurse must act promptly to ensure the patient’s safety. Key nursing interventions include:

• Administer oxygen therapy as prescribed to maintain adequate oxygenation.
• Monitor vital signs, including oxygen saturation, respiratory rate, and heart rate, for changes that indicate worsening hypoxemia or hemodynamic instability.
• Prepare the patient for diagnostic tests such as a CT pulmonary angiography or a D-dimer test to confirm the diagnosis.
• Ensure intravenous access is established for administration of anticoagulants (e.g., heparin) or thrombolytics if prescribed.
• Provide reassurance and emotional support to the patient, as acute dyspnea can cause significant anxiety.

✘Incorrect answer options:

Abnormally slow breathing (bradypnea): Bradypnea is not typically associated with a pulmonary embolism. Instead, patients with PE often exhibit tachypnea (rapid breathing) as a compensatory mechanism to improve oxygen delivery.

A decrease in heart rate (bradycardia): Bradycardia is not a typical finding in PE. Tachycardia (increased heart rate) is more common due to hypoxemia and the body’s response to impaired blood flow in the lungs.

Slower and shallower respiratory effort: Patients with PE often exhibit increased respiratory effort, including rapid and deep breathing (tachypnea), as their bodies attempt to compensate for reduced oxygenation. Shallow breathing is not characteristic of this condition.

EXPLANATION

✔Correct answer:

Encouraging the patient to take three deep breaths. To effectively obtain a sputum specimen, encouraging the patient to take three deep breaths before coughing helps loosen secretions and facilitates the movement of sputum from the lower respiratory tract to the upper airways. This ensures the collected sample is representative of lung secretions and not just saliva from the mouth, which would not be useful for diagnostic purposes.

Deep breathing expands the lungs and mobilizes mucus, making it easier for the patient to produce an adequate sputum sample. Following this, the patient should be instructed to cough forcefully into the collection container to capture the specimen.

Think of shaking a soda bottle (deep breathing) to move all the liquid to the top before opening it (coughing). Similarly, deep breaths help bring sputum up from the lungs for easy collection.

Collecting a sputum specimen requires proper technique and patient preparation to ensure the sample is valid and accurate. Nurse Leah should take the following actions:

• Instruct the patient to perform oral care (e.g., rinse the mouth with water) before the procedure to reduce contamination from oral bacteria.
• Encourage the patient to take several deep breaths, followed by forceful coughing, to mobilize sputum from the lungs.
• Ensure the patient collects the specimen first thing in the morning, when sputum production is typically at its peak.
• Provide a sterile collection container and emphasize the importance of spitting directly into it without contaminating the outside of the container.
• Document the time of collection and promptly send the sample to the laboratory for analysis.

✘Incorrect answer options:

Restricting the patient’s fluid intake: Restricting fluids will make sputum thicker and more difficult to expectorate, hindering specimen collection. Adequate hydration helps thin secretions, making it easier to produce a sample.

Instructing the patient to spit directly into the collection container: Spitting alone is not sufficient for collecting sputum from the lungs. The patient must cough deeply to ensure the specimen comes from the lower respiratory tract, not just saliva from the mouth.

Advising the patient to collect the specimen after a meal: Collecting sputum after a meal increases the risk of contamination with food particles and may also cause nausea or vomiting. The specimen is best obtained early in the morning before eating or drinking.

EXPLANATION

✔Correct answer:

Airborne particles. Tuberculosis (TB) is transmitted through airborne particles, also known as droplet nuclei, that are expelled into the air when an individual with active pulmonary or laryngeal TB coughs, sneezes, speaks, or sings. These particles are extremely small (1-5 microns) and can remain suspended in the air for prolonged periods. When another person inhales these infectious particles, the Mycobacterium tuberculosis bacteria may reach the lungs and initiate infection.

This airborne transmission emphasizes the need for airborne infection isolation precautions, such as the use of negative pressure rooms and N95 respirators for healthcare workers and visitors. Individuals with latent TB are not contagious, and only those with active disease can spread the infection.

Think of TB transmission like blowing glitter into the air. The glitter particles (droplet nuclei) can float around and settle on someone nearby. Similarly, TB bacteria can remain suspended in the air, waiting to be inhaled by someone else.

Nurses play a critical role in preventing TB transmission through patient education and adherence to infection control measures:

• Educate patients with active TB about respiratory hygiene, including covering the mouth when coughing and wearing a surgical mask in public.
• Place patients with suspected or confirmed TB in airborne isolation rooms with negative pressure ventilation.
• Ensure healthcare providers wear properly fitted N95 respirators when caring for TB patients.
• Encourage screening and treatment of high-risk populations, such as close contacts of TB patients and individuals with immunocompromising conditions.
• Reinforce the importance of completing the full course of TB treatment to prevent drug resistance and reduce transmission risk.

✘Incorrect answer options:

Hand-to-mouth contact: TB is not spread through direct contact with contaminated surfaces or objects. Unlike gastrointestinal infections, TB transmission requires inhalation of airborne particles containing the bacteria.

The fecal-oral pathway: TB does not spread through the fecal-oral route. This mode of transmission is typically associated with gastrointestinal diseases such as hepatitis A or cholera, not respiratory infections like TB.

Exposure to blood and body fluids: TB is not transmitted through blood or other body fluids, unlike diseases such as HIV or hepatitis B. TB bacteria are specifically spread through airborne droplets from the respiratory tract.

EXPLANATION

✔Correct answer:

Pain that worsens during inspiration. In patients with a rib fracture, pain that worsens during inspiration is a common and expected finding. Rib fractures cause significant discomfort because the chest wall moves during breathing, particularly during deep inspiration. The movement of the fractured rib irritates the surrounding tissues, leading to sharp pain. As a result, patients may adopt shallow breathing patterns to minimize pain, which can increase the risk of complications such as atelectasis or pneumonia.

This pain, known as pleuritic pain, often limits the patient's ability to take deep breaths or cough effectively, which is why pain management and respiratory support are key priorities in patients with rib fractures.

 Imagine your ribs as hinges on a door, allowing smooth opening and closing (breathing). If one hinge is cracked or broken (rib fracture), every time you try to open the door wide (take a deep breath), it grinds painfully. To avoid the pain, you might only open the door a little (shallow breathing), but this can lead to problems like poor airflow and buildup of debris inside the room (lungs), increasing the risk of complications.

Managing rib fractures involves pain relief, respiratory support, and prevention of complications. Key nursing actions include:

• Administer prescribed pain medications (e.g., NSAIDs, opioids) to improve the patient's ability to breathe deeply and cough.
• Encourage the use of an incentive spirometer to promote lung expansion and prevent atelectasis.
• Teach the patient to splint the chest (e.g., with a pillow) during coughing to reduce pain and improve effectiveness.
• Monitor respiratory status for signs of complications, such as hypoxemia, shallow breathing, or asymmetrical chest movement.
• Encourage ambulation and repositioning to prevent pulmonary complications such as pneumonia.

✘Incorrect answer options:

Slow and deep respirations: Patients with rib fractures typically avoid deep breathing due to pain, leading to shallow respirations rather than slow and deep breathing.

Rapid and deep respirations: Rapid breathing may occur due to pain or anxiety, but it is not typically deep because deep respirations exacerbate pain caused by rib fractures. Patients generally adopt shallow breathing to minimize discomfort.

Paradoxical breathing movements: Paradoxical breathing (inward movement of the chest wall during inspiration and outward movement during expiration) is a hallmark sign of flail chest, a condition involving multiple rib fractures that disrupt the stability of the chest wall. It is not typically seen in a single rib fracture.

EXPLANATION

✔Correct answer:

10 seconds. During tracheostomy suctioning, each suctioning attempt should be limited to 10 seconds to prevent hypoxia and minimize trauma to the airway. Prolonged suctioning can deplete oxygen levels, irritate the mucosa, and potentially trigger bradycardia due to vagal stimulation. By limiting suctioning attempts to 10 seconds or less, Nurse Jake ensures that Mr. Thompson maintains adequate oxygenation and reduces the risk of complications.

If additional suctioning is required, Nurse Jake should allow the patient time to recover between attempts by administering supplemental oxygen and encouraging deep breaths.

Think of suctioning like holding your breath while diving underwater. You can only stay under for a short time before needing air. Similarly, suctioning should be brief to prevent the patient from running out of oxygen.

To ensure patient safety and comfort during suctioning, Nurse Jake should adhere to the following best practices:

• Assess the need for suctioning based on clinical signs, such as audible secretions, low oxygen saturation, or increased respiratory effort.
• Pre-oxygenate the patient with 100% oxygen for 30-60 seconds before suctioning to prevent hypoxia.
• Limit each suctioning pass to 10 seconds and use the lowest suction pressure necessary (typically 80-120 mmHg for adults).
• Allow the patient to rest and recover for 30-60 seconds between suctioning attempts, providing supplemental oxygen as needed.
• Monitor the patient closely for signs of distress, such as cyanosis, bradycardia, or decreased oxygen saturation, and stop suctioning if these occur.

✘Incorrect answer options:

1 minute: Suctioning for 1 minute is far too long and would likely result in severe hypoxia and airway trauma. This is unsafe and could lead to respiratory arrest.

5 seconds: While suctioning for 5 seconds is safe, it may not be sufficient to effectively remove secretions in most cases. The limit of 10 seconds allows enough time for effective secretion removal without causing hypoxia.

30 seconds: Suctioning for 30 seconds is excessively long and would cause significant oxygen depletion and potential airway trauma. This duration is unsafe for tracheostomy suctioning.

EXPLANATION

✔Correct answer:

25 mcg/mL Theophylline has a narrow therapeutic range of 10-20 mcg/mL. A level of 25 mcg/mL is above the therapeutic range and indicates a potential risk of theophylline toxicity, which can lead to serious complications such as nausea, vomiting, tachycardia, arrhythmias, seizures, and even life-threatening conditions. This elevated level should prompt Nurse Anderson to emphasize strict medication compliance, including adherence to the prescribed dose and timing, as well as education about avoiding potential interactions that could further increase drug levels.

Theophylline's metabolism can be influenced by various factors, including liver function, age, concurrent medications, and smoking status. When theophylline levels exceed the therapeutic range, immediate action may be required to reduce the risk of toxicity. Nurse Anderson should also collaborate with the healthcare provider to adjust the dose if needed.

Imagine theophylline levels as the speed of a car. Driving within the speed limit (10-20 mcg/mL) is safe. At 25 mcg/mL, it's like driving over the speed limit—any further acceleration (like dose changes or interactions) can lead to a crash (toxicity).

For a patient with elevated theophylline levels, careful monitoring and education are crucial to ensure safety and prevent toxicity. Key nursing actions include:

• Collaborate with the provider to adjust the theophylline dosage to bring levels within the therapeutic range.
• Educate the patient to take theophylline exactly as prescribed, avoiding missed doses or overdosing.
• Advise the patient to avoid factors that may increase theophylline levels, such as high-fat meals, certain antibiotics (e.g., ciprofloxacin), and caffeine.
• Instruct the patient to report symptoms of toxicity, including nausea, restlessness, palpitations, or seizures, immediately.
• Ensure regular monitoring of serum theophylline levels to maintain them within the therapeutic range.

✘Incorrect answer options:

5 mcg/mL: A level of 5 mcg/mL is below the therapeutic range, which may indicate subtherapeutic dosing and insufficient management of COPD symptoms. While compliance is essential, this level does not raise concerns for toxicity.

10 mcg/mL: This level is at the lower limit of the therapeutic range. It suggests the drug is being administered safely and effectively, provided no symptoms of underdosing are present.

15 mcg/mL: A level of 15 mcg/mL is well within the therapeutic range. While compliance should always be reinforced, this level does not raise significant concerns for toxicity or subtherapeutic effects.

EXPLANATION

✔Correct answer:

2 liters per minute. For patients with emphysema or other forms of chronic obstructive pulmonary disease (COPD), the maximum oxygen flow rate should typically not exceed 2 liters per minute when using nasal cannula therapy. This is because many patients with COPD rely on hypoxic drive to stimulate their breathing. Hypoxic drive is a condition in which low oxygen levels (hypoxemia) serve as the primary trigger for breathing, as opposed to high carbon dioxide levels, which is the normal trigger for most individuals.

Administering oxygen at a flow rate higher than 2 liters per minute can increase oxygen levels too much, suppress the hypoxic drive, and lead to respiratory depression. It is essential to carefully titrate oxygen therapy to maintain adequate oxygenation (e.g., oxygen saturation levels of 88%-92%) while avoiding over-oxygenation.

Think of a car engine designed to run on low-octane fuel. If you suddenly flood it with high-octane fuel, the engine might stop running efficiently or even stall. Similarly, COPD patients' breathing can be suppressed if they are given too much oxygen.

Nurse Julia must monitor the patient’s oxygen therapy closely to ensure it is safe and effective. Key actions include:

• Regularly assess the patient’s respiratory status, including oxygen saturation (SpO₂) and signs of respiratory distress.
• Maintain oxygen flow at 2 liters per minute or lower unless otherwise directed by the healthcare provider.
• Encourage the use of pursed-lip breathing to promote better oxygen exchange and reduce air trapping.
• Educate the patient about conserving oxygen and the importance of adhering to prescribed flow rates.
• Monitor for signs of respiratory depression, such as decreased respiratory rate, somnolence, or altered mental status.

✘Incorrect answer options:

1 liter per minute: While 1 liter per minute is safe for patients with COPD, this is not necessarily the maximum flow rate. Oxygen flow rates of up to 2 liters per minute are typically well-tolerated in these patients.

6 liters per minute: A flow rate of 6 liters per minute is far too high for most COPD patients and can cause over-oxygenation, suppressing hypoxic drive and potentially leading to respiratory failure. Flow rates this high are generally reserved for patients without chronic CO₂ retention or in acute emergencies.

10 liters per minute: This flow rate is extremely high for COPD patients and poses a significant risk of respiratory depression. Such high flow rates are typically used in non-COPD patients requiring high-flow oxygen therapy or with non-rebreather masks in acute, life-threatening situations.

EXPLANATION

✔Correct answer:

Verifying the gag reflex has returned before offering food or drinks. After a bronchoscopy, it is crucial to prioritize the return of the gag reflex before offering any food, drink, or oral medications. During the procedure, local anesthetics are often used to suppress the gag reflex and minimize discomfort while inserting the bronchoscope. Until the gag reflex has fully returned, there is a significant risk of aspiration, which could lead to pneumonia or other complications.

To assess the gag reflex, the nurse can gently stimulate the back of the throat with a tongue depressor. Only after confirming that the patient can adequately protect their airway should the nurse allow oral intake. This intervention ensures the patient's safety and prevents life-threatening complications.

Imagine a car's brakes being temporarily disabled for maintenance (like the suppressed gag reflex during a bronchoscopy). Before driving again (eating or drinking), you need to test and ensure the brakes are working properly (the gag reflex has returned) to avoid accidents (aspiration).

Post-bronchoscopy care involves close monitoring and interventions to ensure a smooth recovery. Key nursing actions include:

• Monitor the patient’s respiratory status, including oxygen saturation, breath sounds, and work of breathing.
• Verify the return of the gag reflex before allowing oral intake to prevent aspiration.
• Provide oxygen therapy as needed to address any post-procedure hypoxemia.
• Reassess for complications such as bleeding (hemoptysis), laryngospasm, or bronchospasm.
• Educate the patient to report symptoms like persistent cough, fever, or difficulty breathing, which may indicate complications.

✘Incorrect answer options:

Administering atropine via IV as part of post-procedure care: Atropine is sometimes administered before a bronchoscopy to reduce secretions, but it is not routinely required after the procedure. There is no indication for post-procedure atropine in this case.

Giving small doses of midazolam for sedation: Midazolam may be used during the procedure for sedation but is not required post-procedure. Post-bronchoscopy care typically focuses on ensuring airway protection and monitoring for complications.

Encouraging the patient to increase fluid intake for the next 24 hours: While maintaining hydration is important for overall recovery, it is not the priority intervention. Fluids should not be offered until the gag reflex has returned to prevent aspiration.

EXPLANATION

✔Correct answer:

Hold the retention sutures to keep the stoma open. If a tracheostomy tube becomes dislodged, the priority is to maintain the patency of the airway. Nurse Sam should immediately hold the retention sutures or use a sterile hemostat to keep the stoma open. This prevents the stoma from closing, which could lead to airway obstruction, a life-threatening emergency. Once the stoma is secured, Nurse Sam can attempt to reinsert a new tracheostomy tube if trained and competent to do so, or call for assistance from a more experienced provider.

Maintaining an open airway takes precedence over other actions, such as contacting other team members or covering the stoma, as time is critical in preventing hypoxia.

Imagine a tunnel collapsing (the stoma closing) after its support beams are removed (the tracheostomy tube dislodging). Holding the retention sutures is like bracing the tunnel walls to keep it open until you can restore proper support (reinsert the tube).

In situations of accidental tracheostomy dislodgement, it is essential to act swiftly to maintain the airway and minimize complications. Key actions include:

• Immediately hold the retention sutures or use a sterile hemostat to keep the stoma open.
• Attempt reinsertion of a new tracheostomy tube if trained to do so. Use a smaller tube if reinsertion is difficult.
• If reinsertion is not possible, maintain the airway by inserting a sterile suction catheter or similar device through the stoma until advanced help arrives.
• Call for additional assistance, including the respiratory therapy team or physician, if reinsertion is unsuccessful.
• Monitor the patient for signs of respiratory distress, such as cyanosis, decreased oxygen saturation, or increased work of breathing.

✘Incorrect answer options:

Notify the physician to reinsert the tube: While notifying the physician is important, it is not the first action. Immediate measures to secure the airway must take precedence to prevent hypoxia.

Contact the respiratory therapy team to reinsert the tracheostomy: Although respiratory therapists are skilled in tracheostomy care, waiting for their arrival could delay critical intervention. Nurse Sam must act immediately to maintain the airway.

Place a sterile dressing over the stoma to reduce infection risk: Covering the stoma would block the airway, worsening the patient’s respiratory distress. Infection control is important but secondary to ensuring airway patency.

EXPLANATION

✔Correct answer:

High-grade fever. High-grade fever (temperature > 39°C or 102°F) is inconsistent with the typical clinical presentation of tuberculosis (TB). Patients with active TB often experience low-grade fever, especially in the late afternoon or evening. This is a hallmark symptom of TB, along with night sweats, fatigue, and weight loss. A high-grade fever may suggest a concurrent condition, such as a secondary infection, sepsis, or another underlying illness.

It is crucial to investigate the cause of a high-grade fever in a patient with TB, as it is not typically caused by TB alone. Co-infections, such as pneumonia or HIV-related opportunistic infections, are common in patients with TB and may present with more pronounced febrile responses.

Think of TB like a slow-burning candle (low-grade fever) that consistently emits a dim glow. If the light suddenly flares brightly (high-grade fever), it suggests that another match (secondary infection) has been struck, adding to the fire.

When a high-grade fever is observed in a patient with TB, the nurse should prioritize further evaluation and monitoring to identify and treat any additional conditions. Key nursing actions include:

• Report the presence of high-grade fever to the healthcare provider immediately for further investigation.
• Assess for signs and symptoms of a concurrent infection, such as pneumonia (e.g., productive cough, purulent sputum) or urinary tract infection (e.g., dysuria, flank pain).
• Obtain blood cultures, sputum cultures, or other relevant diagnostic tests to identify potential sources of infection.
• Monitor vital signs regularly, paying close attention to trends in temperature, heart rate, and blood pressure.
• Administer antipyretics as prescribed to manage fever and promote patient comfort.

✘Incorrect answer options:

Persistent cough: A persistent cough is one of the hallmark symptoms of TB. Initially, the cough may be dry, but it often progresses to become productive, sometimes with blood-streaked sputum (hemoptysis) in advanced stages.

Chills and night sweats: Night sweats are a classic symptom of TB and occur as part of the systemic inflammatory response to the infection. They are commonly associated with TB and are expected in the clinical presentation.

Anorexia and noticeable weight loss: Weight loss and anorexia are common in TB patients due to systemic inflammation, reduced appetite, and increased metabolic demands caused by the chronic infection. This finding aligns with the expected symptoms of TB.

EXPLANATION

✔Correct answer:

Emphysema. The presence of a barrel chest is most commonly associated with emphysema, a form of chronic obstructive pulmonary disease (COPD). In emphysema, the alveoli lose their elasticity, leading to air trapping and hyperinflation of the lungs. This chronic overdistension of the lungs causes the rib cage to remain partially expanded, giving the chest a rounded, barrel-like appearance. Over time, this structural change becomes more pronounced due to increased anterior-posterior chest diameter.

The hallmark features of emphysema include dyspnea on exertion, decreased breath sounds, and hyperresonance on percussion, in addition to the barrel chest.

Think of the lungs like balloons that are inflated but can’t fully deflate because of a tied knot (air trapping). Over time, the balloons (lungs) stretch the container they’re in (the chest), making it rounder, like a barrel.

Patients with emphysema require careful monitoring and management to prevent further lung damage and improve quality of life. Key nursing actions include:

• Encourage smoking cessation to slow the progression of lung damage.
• Teach and reinforce breathing techniques, such as pursed-lip breathing, to reduce air trapping and improve ventilation.
• Provide oxygen therapy as prescribed, ensuring careful titration to avoid suppressing the patient’s hypoxic drive.
• Promote pulmonary hygiene, including hydration and airway clearance techniques, to reduce secretions.
• Monitor for signs of respiratory distress, such as cyanosis or worsening dyspnea, and notify the healthcare provider promptly if symptoms escalate.

✘Incorrect answer options:

Bronchial asthma: Asthma is primarily an inflammatory airway condition characterized by episodic bronchospasm, wheezing, and reversible airflow obstruction. It does not cause the chronic air trapping or lung hyperinflation associated with a barrel chest.

Chronic obstructive bronchitis: Chronic bronchitis is another form of COPD, characterized by excessive mucus production, chronic productive cough, and airway inflammation. While it may contribute to airflow limitation, it does not typically result in a barrel chest unless combined with emphysema.

A combination of asthma and bronchitis: While asthma and bronchitis together may cause airflow limitation, this combination does not result in the structural changes (barrel chest) seen with emphysema.

EXPLANATION

✔Correct answer:

Take no action, as this is a normal and expected observation. Continuous gentle bubbling in the suction control chamber of a chest drainage system is normal and expected when the system is connected to suction. This bubbling occurs because the suction control chamber is venting excess air as it regulates the pressure applied to the chest tube. The purpose of the suction control chamber is to maintain negative pressure within the pleural space, which facilitates lung re-expansion in cases of pneumothorax or other conditions requiring chest tube drainage.

As long as the bubbling is confined to the suction control chamber and not the water seal chamber, this finding is appropriate and indicates that the system is functioning correctly. Nurse Kim should document this observation and continue routine monitoring of the chest drainage system.

Think of the suction control chamber like a controlled leak in a pressure valve. The gentle bubbling is like a small, consistent release of air that prevents too much pressure from building up—this ensures the system is working properly without overdoing it.

Proper management of a patient with a chest tube requires vigilant monitoring to detect any abnormalities or complications. Key actions include:

• Verify that the chest drainage system is set up correctly, with suction pressure as prescribed by the healthcare provider.
• Monitor for continuous bubbling in the water seal chamber, which may indicate an air leak.
• Ensure the chest tube remains patent and free of kinks or blockages.
• Assess the patient for signs of respiratory distress, subcutaneous emphysema, or worsening pneumothorax.
• Document findings and communicate any significant changes or abnormalities to the healthcare provider.

✘Incorrect answer options:

Clamp the chest tube right away and contact the healthcare provider: Clamping the chest tube is contraindicated unless specifically instructed by the provider or during certain diagnostic procedures. Clamping can result in a buildup of air in the pleural space, worsening the pneumothorax and potentially leading to a tension pneumothorax—a life-threatening emergency.

Investigate for an air leak since bubbling should occur intermittently: While intermittent bubbling in the water seal chamber may indicate air drainage from the pleural space, continuous gentle bubbling in the suction control chamber is normal and does not indicate an air leak.

Increase the suction pressure until the bubbling becomes more vigorous: Increasing suction pressure unnecessarily can lead to lung tissue damage, air leaks, or other complications. The prescribed suction level (commonly -20 cm H₂O) is sufficient for therapeutic purposes, and vigorous bubbling is not required for effective suction.

EXPLANATION

✔Correct answer:

Metabolic acidosis. The ABG results indicate metabolic acidosis, characterized by a low pH (7.30) and a low bicarbonate level (HCO₃) with normal carbon dioxide (PaCO₂). Metabolic acidosis occurs when there is either an excess of acid (e.g., lactic acid, ketones) or a loss of bicarbonate (e.g., due to diarrhea or renal dysfunction), leading to a decrease in blood pH.

The elevated potassium level is another indicator of metabolic acidosis. When the blood becomes acidic, hydrogen ions enter cells in exchange for potassium ions, leading to hyperkalemia. This finding further supports the diagnosis. The normal PaCO₂ and oxygen levels indicate that the respiratory system has not yet compensated or is minimally compensating for the metabolic derangement.

Think of the blood as a swimming pool with a filter (bicarbonate) to maintain pH balance. In metabolic acidosis, the filter isn’t working properly or acid (like extra leaves) overwhelms the pool, making it acidic. Here, the lungs haven’t yet stepped in (normal carbon dioxide) to help balance the pool by "scooping out" the leaves (acid).

Managing metabolic acidosis requires identifying and addressing the underlying cause. Nurse actions include:

• Administer bicarbonate therapy if prescribed to correct severe acidosis (e.g., pH <7.2).
• Monitor potassium levels closely, as correcting acidosis can lead to hypokalemia.
• Assess renal function, as kidney impairment is a common cause of bicarbonate loss.
• Monitor for signs of respiratory compensation, such as tachypnea or Kussmaul breathing.
• Collaborate with the healthcare team to treat the root cause, such as diabetic ketoacidosis (DKA), lactic acidosis, or sepsis.

✘Incorrect answer options:

Respiratory acidosis: Respiratory acidosis occurs when PaCO₂ is elevated due to hypoventilation, leading to a decreased pH. In this case, the PaCO₂ is normal, ruling out respiratory acidosis.

Overcompensated respiratory acidosis: Overcompensation would result in a high bicarbonate level (HCO₃) due to metabolic compensation for respiratory acidosis, which is not seen here. Additionally, the concept of "overcompensation" is physiologically rare, as the body typically does not overcorrect acid-base imbalances.

Combined metabolic and respiratory acidosis: Combined acidosis would involve abnormalities in both bicarbonate (HCO₃) and carbon dioxide (PaCO₂) levels. In this case, the PaCO₂ is normal, indicating no respiratory component to the acidosis.

EXPLANATION

✔Correct answer:

Evidence of a hyperinflated chest on the chest X-ray. In patients with chronic obstructive pulmonary disease (COPD), particularly during an acute exacerbation, a common finding is hyperinflation of the lungs on a chest X-ray. This occurs because COPD leads to air trapping and difficulty in exhaling fully due to loss of elastic recoil in the lungs and obstruction of airflow. Hyperinflation causes the lungs to expand more than normal, often resulting in a flattened diaphragm and an increased anterior-posterior (AP) diameter of the chest (commonly referred to as a "barrel chest").

The hyperinflation seen on the chest X-ray is an expected finding in COPD patients and is useful for confirming the diagnosis or assessing disease progression. During acute exacerbations, this condition is often accompanied by worsening dyspnea, hypoxemia, and hypercapnia.

Imagine a balloon that gets inflated but cannot completely deflate due to a knot in the neck. This trapped air causes the balloon (lungs) to remain expanded, just like in lung hyperinflation with COPD.

During an acute exacerbation of COPD, the focus is on relieving symptoms, improving oxygenation, and preventing complications. Key nursing actions include:

• Administer prescribed bronchodilators and corticosteroids to reduce airway inflammation and improve airflow.
• Provide oxygen therapy as needed, ensuring careful titration to avoid worsening hypercapnia in CO₂-retaining patients.
• Encourage pursed-lip breathing to help patients exhale more fully and reduce air trapping.
• Monitor for signs of respiratory failure, such as altered mental status, increasing dyspnea, or worsening oxygenation.
• Educate the patient on energy conservation techniques and the importance of smoking cessation to prevent further lung damage.

✘Incorrect answer options:

Low carbon dioxide levels (hypocapnia): COPD exacerbations are more commonly associated with hypercapnia (elevated carbon dioxide levels) due to impaired gas exchange and difficulty exhaling CO₂. Hypocapnia would be unusual and is more characteristic of conditions like hyperventilation syndrome.

Improved oxygen saturation during physical activity: COPD patients typically experience worsening oxygen saturation during physical activity due to increased oxygen demand and compromised respiratory function. Exercise intolerance is a hallmark of COPD.

Observation of a widened diaphragm on the chest X-ray: In COPD, the diaphragm is usually flattened rather than widened due to lung hyperinflation. A flattened diaphragm reduces the efficiency of respiratory muscle function and contributes to dyspnea.

EXPLANATION

✔Correct answer:

Inhales the mist and exhales immediately afterward. If Mr. Johnson inhales the medication mist and exhales immediately afterward, this indicates a need for further instruction. To maximize the medication's effectiveness, the patient should hold their breath for 10 seconds after inhaling the mist. This allows the medication to deposit in the airways, ensuring proper absorption and therapeutic effect. Exhaling immediately reduces the amount of medication that reaches the lungs and decreases its effectiveness.

Proper inhaler technique is crucial for managing asthma and ensuring that medications, such as bronchodilators or corticosteroids, are delivered effectively to the lower airways.

Using an inhaler is like watering plants. If you spray the water and pull the hose away too quickly (exhaling immediately), the plants (lungs) won’t get enough water (medication). Holding your breath gives the "water" time to soak into the "roots."

Nurse education is critical to ensure proper inhaler use. The following steps outline correct inhaler technique:

• Remove the cap and shake the inhaler thoroughly to mix the medication properly.
• Exhale completely before positioning the inhaler to ensure the lungs are ready to take in the medication.
• Place the inhaler mouthpiece between the lips, forming a tight seal, or position it just outside the mouth if using a spacer.
• Press the canister down and inhale deeply and slowly over 3-5 seconds to ensure the medication reaches the lower airways.
• Hold the breath for 10 seconds after inhaling to allow proper absorption of the medication in the lungs.
• Wait 1-2 minutes between puffs if a second dose is prescribed, allowing time for the medication to take effect.

✘Incorrect answer options:

Removes the cap and thoroughly shakes the inhaler before using it: This action is correct. Shaking the inhaler ensures that the medication is evenly distributed in the canister and ready for use.

Presses the canister down while inhaling deeply: This is also correct. Coordinating the pressing of the canister with a deep inhalation ensures that the medication is properly delivered to the airways.

Waits 1 to 2 minutes between puffs if prescribed more than one dose: This is another correct action. Waiting between puffs improves medication effectiveness, as the first dose helps open the airways, allowing the second dose to penetrate deeper into the lungs.

EXPLANATION

✔Correct answer:

Development of a right-sided pneumothorax. The sudden onset of absent breath sounds in the right upper lung lobe and the activation of the high-pressure alarm on the mechanical ventilator strongly suggest the development of a right-sided pneumothorax. A pneumothorax occurs when air enters the pleural space, causing the lung to collapse and impair ventilation. This increases airway resistance, leading to high-pressure alarms on the ventilator. Absent breath sounds on the affected side are a key clinical finding in this condition.

A pneumothorax is a medical emergency, as it can progress to a tension pneumothorax, causing hemodynamic instability, tracheal deviation, and potentially life-threatening respiratory compromise. Immediate assessment and intervention are required to confirm the diagnosis and relieve the pressure in the pleural space, typically through needle decompression or chest tube insertion.

Imagine a balloon (the lung) inside a sealed box (the pleural cavity). If the balloon gets punctured, air escapes into the box, squishing the balloon flat. This prevents the balloon from expanding and triggers alarms as the system struggles to push air into it.

The nurse must act promptly to address the possibility of a pneumothorax. Key actions include:

• Immediately assess the patient's respiratory status, including oxygen saturation, respiratory effort, and chest symmetry.
• Notify the healthcare provider immediately to initiate emergency interventions such as chest X-ray confirmation or needle decompression.
• Monitor for signs of a tension pneumothorax, such as tracheal deviation, hypotension, and cyanosis.
• Prepare for chest tube insertion to re-expand the lung and evacuate air from the pleural space.
• Provide supplemental oxygen to support oxygenation while awaiting intervention.

✘Incorrect answer options:

Presence of a pulmonary embolism: A pulmonary embolism could cause acute respiratory distress and hypoxemia but would not explain the absent breath sounds in one lung or the high-pressure alarm. It typically presents with sudden dyspnea, chest pain, and tachycardia.

Displacement of the endotracheal tube: While tube displacement can lead to abnormal ventilation, it often results in absent or decreased breath sounds bilaterally (or only in one lower lobe if the tube migrates into a main bronchus). It would not specifically explain absent breath sounds only in the right upper lobe.

Onset of acute respiratory distress syndrome (ARDS): ARDS is a progressive condition characterized by widespread inflammation and non-cardiogenic pulmonary edema. It presents with bilateral crackles or diminished breath sounds but does not typically cause absent breath sounds in one lobe or a sudden high-pressure alarm.

EXPLANATION

✔Correct answer:

Use the Valsalva maneuver. During chest tube removal, the patient is instructed to perform the Valsalva maneuver, which involves taking a deep breath, holding it, and bearing down as though attempting to exhale against a closed airway. This action increases intrathoracic pressure, preventing air from entering the pleural space as the chest tube is removed. The Valsalva maneuver helps reduce the risk of developing a pneumothorax after the tube is taken out.

Once the tube is removed, the healthcare provider quickly applies an occlusive dressing over the site to maintain a seal and prevent air re-entry. Nurse Mia's role is to ensure that the patient understands and correctly performs the maneuver at the right moment during the procedure.

Think of the chest tube site like a cork being removed from a bottle. To prevent air (like outside liquid) from rushing into the bottle (pleural space), you "pressurize" the bottle (using the Valsalva maneuver), making it harder for air to enter.

Nurse Mia must ensure that the patient is prepared for the chest tube removal and that the procedure is performed safely. Key actions include:

• Explain the Valsalva maneuver to the patient and practice it beforehand if necessary.
• Reassure the patient about the procedure and provide emotional support to minimize anxiety.
• Position the patient appropriately (usually in a semi-Fowler's position) to facilitate the procedure.
• Monitor the patient for signs of respiratory distress or complications, such as re-accumulation of air or fluid in the pleural space.
• Ensure that the occlusive dressing is properly secured over the chest tube site after removal.

✘Incorrect answer options:

Breathe out slowly: Exhaling slowly does not sufficiently increase intrathoracic pressure, which is necessary to prevent air from entering the pleural space during tube removal. This instruction would not be effective in preventing a pneumothorax.

Remain completely still: While it is important for the patient to remain still to avoid complicating the procedure, this alone does not prevent air from entering the pleural space. The Valsalva maneuver is the critical action.

Take rapid breaths in and out: Rapid breathing would likely cause fluctuations in intrathoracic pressure and could increase the risk of air entering the pleural space during tube removal. This is not an appropriate instruction.

EXPLANATION

✔Correct answer:

Signs of bronchospasm. Bronchospasm is a serious complication that may occur after a bronchoscopy and biopsy. It involves the sudden constriction of the muscles in the bronchial walls, leading to airway narrowing and potentially severe respiratory distress. Signs of bronchospasm include wheezing, dyspnea, decreased oxygen saturation, and increased work of breathing. This finding requires immediate reporting to the physician, as it may necessitate emergency interventions such as bronchodilator administration, oxygen therapy, or even intubation to secure the airway.

Bronchospasm may occur due to irritation of the airways from the procedure, allergic reactions, or hypersensitivity to local anesthetics or sedatives used during the bronchoscopy. Prompt action is essential to prevent hypoxia and ensure the patient's safety.

Imagine a drinking straw that suddenly gets pinched in the middle, making it difficult for liquid (air) to pass through. Bronchospasm is like this pinching of the airways, and without intervention, it becomes harder for the patient to breathe.

Nurse Sarah should carefully monitor for complications after a bronchoscopy and intervene promptly. Key actions include:

• Continuously monitor respiratory status, including oxygen saturation, respiratory rate, and effort of breathing.
• Report signs of bronchospasm, such as wheezing or difficulty breathing, to the physician immediately.
• Prepare to administer prescribed medications, such as bronchodilators or corticosteroids, to relieve airway constriction.
• Provide oxygen therapy as needed to maintain adequate oxygenation.
• Reassure and support the patient, as respiratory distress can cause significant anxiety.

✘Incorrect answer options:

A dry, non-productive cough: A mild cough is expected after a bronchoscopy due to temporary airway irritation. This does not require immediate reporting unless it becomes severe or persistent.

Hematuria: Hematuria (blood in the urine) is unrelated to a bronchoscopy and would not be an expected finding after this procedure. While this would need evaluation in a different context, it is not relevant to this scenario.

Sputum with streaks of blood: Small amounts of blood-tinged sputum are a normal finding after a bronchoscopy, particularly if a biopsy was performed. This occurs due to minor irritation or trauma to the airway. However, large amounts of bright red blood (indicating hemorrhage) would be a cause for concern and should be reported immediately.

EXPLANATION

✔Correct answer:

Submerge the end of the chest tube into a bottle of sterile water. If a chest tube accidentally disconnects from its drainage system, the priority is to prevent air from entering the pleural space, which could worsen the pneumothorax or lead to a life-threatening tension pneumothorax. Submerging the end of the chest tube into a bottle of sterile water creates an immediate water seal, which acts as a one-way valve. This allows air to escape from the pleural space during exhalation while preventing air from re-entering during inhalation. This quick action helps maintain negative pressure within the pleural cavity until the chest tube system can be reconnected or replaced.

This intervention is the safest and most effective initial action to stabilize the situation and minimize the risk of complications while awaiting further measures.

Think of the chest tube like a straw in a drink. If the straw is removed from the drink and left open to the air, it allows air to flow both in and out, causing problems. Placing the end of the straw back into the drink (sterile water) creates a one-way system where air can escape but not enter.

After addressing the immediate disconnection, further actions are needed to ensure patient safety and system functionality:

• Secure the disconnected chest tube into a sterile water seal as a temporary measure.
• Assess the patient’s respiratory status for any signs of distress, such as increased work of breathing or diminished breath sounds.
• Re-establish connection to the chest drainage system or set up a new drainage system as soon as possible, using sterile technique.
• Notify the healthcare provider of the incident and any significant changes in the patient’s condition.
• Educate the patient about avoiding excessive movement or pulling on the chest tube to prevent future disconnections.

✘Incorrect answer options:

Contact the physician for further instructions: While notifying the physician is important after addressing the situation, it should not be the initial action. The priority is to create a water seal to prevent air from entering the pleural space.

Quickly set up and connect a new chest tube system: Setting up a new drainage system takes time, and leaving the chest tube open to air while doing so risks worsening the patient’s condition. Temporarily submerging the chest tube in sterile water is faster and safer as an initial action.

Cover the disconnected site with a sterile dressing immediately: Placing a sterile dressing over the disconnection does not create a water seal and may block air from escaping, increasing the risk of a tension pneumothorax. This is not the correct intervention in this scenario.

EXPLANATION

✔Correct answer:

Within the normal range and anticipated. A pulmonary capillary wedge pressure (PCWP) of 12 mm Hg is within the normal range (6-12 mm Hg) and is anticipated in acute respiratory distress syndrome (ARDS). This finding helps differentiate ARDS from cardiogenic pulmonary edema, as ARDS is characterized by non-cardiogenic pulmonary edema due to increased capillary permeability rather than elevated pressures in the left heart.

In ARDS, the pulmonary edema is caused by widespread inflammation and damage to the alveolar-capillary membrane, not by increased hydrostatic pressure as seen in conditions like left-sided heart failure. A normal PCWP supports the diagnosis of ARDS and rules out significant left ventricular dysfunction as the cause of pulmonary edema.

Think of ARDS like a leaking garden hose (damaged capillary membranes) causing water to flood the yard (lungs). The problem isn’t pressure from the faucet (normal PCWP), but rather the holes in the hose allowing water to escape where it shouldn’t.

The nurse should continue to monitor Mr. Brown’s hemodynamic and respiratory status closely to guide treatment and detect complications. Key actions include:

• Regularly assess and document PCWP values to differentiate ARDS from cardiogenic pulmonary edema.
• Monitor oxygenation and ventilation parameters, such as arterial blood gases (ABGs) and oxygen saturation, to guide respiratory support.
• Collaborate with the healthcare team to implement strategies such as low tidal volume ventilation, prone positioning, or the use of PEEP (positive end-expiratory pressure).
• Monitor for complications of ARDS, such as barotrauma or multi-organ dysfunction syndrome (MODS).
• Educate the patient’s family about ARDS, the treatment plan, and the importance of close monitoring.

✘Incorrect answer options:

Elevated but consistent with ARDS: A PCWP above the normal range (e.g., >18 mm Hg) would suggest cardiogenic pulmonary edema, not ARDS. Elevated PCWP indicates left ventricular dysfunction or fluid overload, which are inconsistent with ARDS.

Lower than expected for ARDS: A low PCWP (<6 mm Hg) is not typical of ARDS. While ARDS is associated with normal PCWP, low values might indicate hypovolemia, which would require a different intervention.

Ambiguous and not typical for ARDS: A normal PCWP is both typical and expected in ARDS, making this option incorrect. The PCWP provides important information to confirm ARDS as a non-cardiogenic cause of pulmonary edema.

EXPLANATION

✔Correct answer:

Maintain ongoing monitoring of the patient. The fluctuation (or "tidaling") of the fluid level in the water seal chamber of a chest drainage system is normal and expected in a patient with a functioning chest tube. This fluctuation reflects changes in intrapleural pressure during the respiratory cycle: the water level rises during inhalation and falls during exhalation. Tidaling indicates that the chest tube is patent and that there is no obstruction or kink in the tubing.

Nurse Laura should take no immediate corrective action but should continue to monitor the patient and document this expected finding. If tidaling were absent, this might indicate a blocked or kinked chest tube, lung re-expansion, or disconnection of the system, and further investigation would be needed.

Imagine the water seal chamber like a swinging door in a busy hallway. As people walk through the door (representing air movement during breathing), the door gently swings back and forth (tidaling). This movement shows the door is working properly and the hallway (the chest tube system) is open and unobstructed. If the door stops swinging entirely, it could mean the hallway is blocked (a kinked tube) or no one is coming through anymore (lung re-expansion or disconnection).

Nurse Laura should focus on continuous assessment of the chest tube system and the patient’s condition to ensure optimal functioning and early detection of complications. Key actions include:

• Monitor for consistent tidaling in the water seal chamber during respiration.
• Check for absence of tidaling, which may suggest lung re-expansion, tubing obstruction, or system disconnection.
• Observe for excessive or continuous bubbling in the water seal chamber, which may indicate an air leak.
• Assess the patient for respiratory status, pain, and signs of complications such as subcutaneous emphysema or worsening pneumothorax.
• Document findings, including the presence of tidaling, drainage characteristics, and the patient’s overall condition.

✘Incorrect answer options:

Notify the physician of the finding: Tidaling is an expected observation and does not require immediate notification of the physician. This is only necessary if there are abnormal findings, such as absence of tidaling (suggesting a potential obstruction or resolved pneumothorax) or continuous bubbling indicating an air leak.

Secure the occlusive dressing with additional reinforcement: Reinforcing the occlusive dressing is unnecessary unless there is evidence of dressing displacement, air leakage at the insertion site, or visible complications. This action is not related to the observed tidaling in the water seal chamber.

Instruct the patient to perform deep-breathing exercises: While deep-breathing exercises are important for promoting lung expansion and preventing complications like atelectasis, they are not a specific response to the observation of tidaling. Deep-breathing exercises are part of routine care, not an immediate action for this finding.

EXPLANATION

✔Correct answer:

Findings from a sputum culture. The sputum culture is the gold standard for confirming a diagnosis of tuberculosis (TB). This test identifies the presence of Mycobacterium tuberculosis in the patient's sputum, providing definitive evidence of active TB infection. While the results of a sputum culture can take several weeks (due to the slow growth of the bacterium), it is the most reliable diagnostic tool for TB. A series of at least three early morning sputum samples is typically collected to increase diagnostic accuracy.

Sputum smear microscopy for acid-fast bacilli (AFB) may provide quicker preliminary results, but it is less specific and can show false positives due to other mycobacteria. The culture, along with drug sensitivity testing, is essential for confirming TB and guiding treatment decisions, especially in cases of multidrug-resistant TB (MDR-TB).

Think of the sputum culture like sending a sample to a specialized lab to grow a specific plant from its seed. If the plant grows (Mycobacterium tuberculosis), it confirms exactly what you're dealing with and helps determine the right "tools" (antibiotics) to treat it.

During the diagnostic process, Nurse Andrea plays a key role in ensuring the correct collection and handling of samples and supporting the patient emotionally and physically:

• Educate the patient on proper sputum collection techniques, such as coughing deeply to produce a sample from the lungs, not saliva.
• Ensure timely delivery of collected samples to the laboratory in accordance with infection control protocols.
• Place the patient in airborne isolation until the diagnosis of TB is confirmed or ruled out.
• Reinforce the importance of completing the diagnostic process to prevent delays in treatment.
• Provide emotional support, as patients may feel anxious or isolated during this process.

✘Incorrect answer options:

Results from a bronchoscopy: A bronchoscopy can be used to obtain respiratory specimens when patients cannot produce sputum, but it is not the primary diagnostic tool. Sputum samples are less invasive and preferred as the first-line test for TB.

Imaging from a chest X-ray: A chest X-ray can suggest TB by showing abnormalities such as cavitations, infiltrates, or nodules, but it is not specific for TB. These findings may also appear in other lung diseases, such as pneumonia or lung cancer. A chest X-ray supports diagnosis but cannot confirm it.

Outcome of a tuberculin skin test: The tuberculin skin test (TST) detects prior exposure to Mycobacterium tuberculosis but does not confirm active disease. A positive result indicates TB infection (latent or active), but further testing, such as a sputum culture, is required to confirm active TB.

EXPLANATION

✔Correct answer:

The presence of stridor. Stridor is a high-pitched, wheezing sound caused by upper airway obstruction or narrowing. Following endotracheal tube removal, stridor indicates potential laryngeal edema, airway spasm, or partial obstruction, all of which can quickly progress to complete airway obstruction and respiratory arrest if not addressed promptly. This is a medical emergency, and Nurse Ellen must report it immediately so that interventions, such as administration of racemic epinephrine, corticosteroids, or reintubation, can be initiated to secure the airway.

Post-extubation stridor is particularly concerning because the patient no longer has a secured airway via an endotracheal tube. Immediate intervention is critical to prevent life-threatening complications such as severe hypoxia or respiratory failure.

Think of the airway like a narrow bridge. If a tree branch falls on the bridge (stridor caused by swelling or narrowing), traffic (air) slows down, and if not cleared quickly, the bridge could become completely blocked, stopping all traffic.

If stridor is observed post-extubation, immediate steps must be taken to manage the situation and ensure patient safety. These include:

• Immediately report the presence of stridor to the healthcare provider.
• Prepare for possible reintubation or other airway management interventions.
• Administer humidified oxygen as prescribed to reduce airway irritation and maintain adequate oxygenation.
• Anticipate orders for racemic epinephrine nebulization to reduce airway swelling.
• Monitor for signs of worsening respiratory distress, such as increased work of breathing, cyanosis, or decreased oxygen saturation.

✘Incorrect answer options:

Small amounts of pink-tinged sputum: Pink-tinged sputum may be expected post-extubation due to minor trauma to the airway during the removal process. While this finding should be documented, it is not a critical concern unless the sputum becomes copious or bright red, which could indicate active bleeding.

Mild crackles heard at the base of the right lung: Mild crackles are not uncommon post-extubation due to atelectasis or retained secretions. They should be monitored, and interventions such as incentive spirometry and deep breathing exercises can help resolve them. This finding does not require immediate reporting unless associated with worsening respiratory status.

A respiratory rate of 24 breaths per minute: While slightly elevated, a respiratory rate of 24 breaths per minute is not unusual post-extubation as the patient adjusts to breathing without ventilatory support. This finding requires ongoing monitoring but is not an emergency unless the rate becomes dangerously high or is accompanied by other signs of distress.

EXPLANATION

✔Correct answer:

Hold your breath briefly after inhaling the dose. One of the most important steps in using a metered-dose inhaler (MDI) is to hold your breath for about 10 seconds after inhaling the medication. This allows the medication to settle in the lungs and be absorbed effectively, ensuring maximum therapeutic benefit. Exhaling immediately after inhaling the dose would expel much of the medication, reducing its effectiveness.

Holding the breath briefly ensures that the medication reaches the deeper airways where it can exert its intended effects, such as relieving bronchoconstriction or reducing inflammation.

Think of using an MDI like spraying paint onto a surface. Holding your breath after inhaling is like pausing to let the paint settle on the surface (lungs), so it sticks and works effectively. Without pausing, the "paint" might blow away before it can do its job.

The nurse should ensure that Mr. Allen understands all steps for proper MDI use. Key instructions include:

• Remove the cap and shake the inhaler thoroughly to mix the medication.
• Exhale completely before positioning the inhaler to prepare the lungs to receive the medication.
• Place the mouthpiece in your mouth, forming a tight seal with your lips, or use a spacer if prescribed.
• Press the canister down while inhaling slowly and deeply for 3-5 seconds.
• Hold your breath for 10 seconds after inhaling to allow the medication to reach the airways.
• Wait at least 1 minute between puffs if a second dose is prescribed.

✘Incorrect answer options:

Inhale the medication rapidly: Rapid inhalation is ineffective as it causes the medication to deposit in the upper airways rather than reaching the lungs. Inhalation should be slow and deep to ensure proper drug delivery to the lower airways.

Use the nose to inhale the medication: The medication must be inhaled through the mouth, not the nose, as MDIs are designed to deliver the drug directly into the airways via oral inhalation.

Take two puffs of medication in a single breath: Taking two puffs in one breath is incorrect because the lungs cannot accommodate two doses at once, and much of the medication will be wasted. The patient should take one puff per breath and wait at least 1 minute between doses if multiple puffs are prescribed.

EXPLANATION

✔Correct answer:

Paradoxical chest wall movement. The hallmark symptom of flail chest is paradoxical chest wall movement, where the injured segment of the chest wall moves inward during inspiration (when the rest of the chest expands) and outward during expiration (when the rest of the chest deflates). This occurs because the fractured ribs lose stability, detaching the injured portion of the chest wall from the rest of the rib cage.

Paradoxical movement disrupts normal ventilation, leading to inefficient breathing, reduced oxygenation, and respiratory distress. This distinctive finding is specific to flail chest and is caused by multiple rib fractures in two or more consecutive ribs, leading to a "floating" segment of the chest wall.

Imagine a rowboat with a loose plank in the middle of its floor. When you step on the boat to push it forward (inspiration), the loose plank sinks downward instead of staying level with the rest of the boat. When you try to pull back (exhalation), the plank rises instead of staying stable. This irregular movement disrupts the boat’s balance, much like how paradoxical chest wall movement disrupts normal breathing in flail chest.

Flail chest is a serious condition that compromises respiratory function and requires immediate intervention. Key nursing actions include:

• Provide oxygen therapy to maintain adequate oxygenation and reduce respiratory distress.
• Monitor for signs of respiratory failure, such as increased work of breathing, low oxygen saturation, or cyanosis.
• Position the patient in a semi-Fowler's or Fowler's position to promote lung expansion and reduce discomfort.
• Prepare for mechanical ventilation if respiratory effort becomes insufficient.
• Manage pain effectively to allow the patient to take deep breaths and prevent complications such as atelectasis or pneumonia.

✘Incorrect answer options:

The presence of cyanosis: While cyanosis may occur in severe cases due to hypoxemia, it is not specific to flail chest and can also be seen in other respiratory conditions.

Low blood pressure (hypotension): Hypotension is not a hallmark sign of flail chest. It may occur in severe cases if the patient develops associated complications, such as hypovolemic shock or cardiac injury.

Difficulty breathing, especially during exhalation: Although difficulty breathing (dyspnea) is common in flail chest, it is not specific to the condition. The hallmark sign is paradoxical chest wall movement, which directly indicates the loss of chest wall stability.