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Advanced Nursing Skills ATI Final questions & answers.
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Advanced Nursing Skills ATI Finalquestions & answers.
Oropharyngeal airway ANS -
Nasopharyngeal airway ANS -
Endotracheal tube ANS -
Tracheostomy tube ANS -
Which artificial airway stimulates the gag reflex and should only be used for patients who's
LOC is altered? ANS - Oropharyngeal
Which tube?
Correct size is measured from the corner of the mouth to the angle of the jaw ANS -
Oropharyngeal
Which tube?
Can be used for alert patients and is measured from the patient's nose to the angle of the
jaw. ANS - Nasopharyngeal
Which tube?
-general anesthesia surgery
-mechanical ventilation
-can insert in nose or mouth
-extends all the way down to trachea bifurcation
-cuff
-size and length depend on pt age/size
-left no longer than 14 days (risk of infection) ANS - Endotracheal
A nurse is planning education for a patient who has a chest tube in place attached to a
closed-chest drainage system following surgery for lung cancer. Which of the following
should the nurse emphasize to the patient when he is ready to ambulate freely? ANS - Keep
the collection device upright at all times
*The closed-chest drainage system must be upright at all times to ensure that the tubing
drains optimally and the system functions correctly.
, A nurse is caring for a patient who has a chest tube in place attached to water-seal drainage.
Which of the following abservations about the drainage should be reported if found 5 hr
after insertion? ANS - About 150 mL/hr over the past 2 hr
*After the first fer hours, the nurse should report drainage that exceeds 70 mL/hr. Patients
who lose as much as 100 mL of blood every 15 min might require autotransfusion within 6
hr.
A nurse is assessing a patient who has a chest tube in place attached to a closed-chest
water-seal drainage system. When the nurse palpates the area around the chest-tube
insertion site, she is checking for ANS - Subcutaneous emphysema
*Palpating the area surrounding the insertion site helps identify crepitus, a dry, crackling, or
grating sound. This is the classic manifestation of subcutaneous emphysema, which
indicates that air is leaking into the subcutaneous tissue surrounding the chest-tube
insertion site.
A nurse is caring for a patient who is 6 hr postoperative and has a chest tube in place
attached to a closed-chest water-seal drainage system. The nurse should observe for which
of the following indications of a problem in the drainage system? ANS - Continuous bubbling
in the water-seal chamber
*Excessive and continuous bubbling in the water-seal chamber indicates an air leak in the
drainage system. The nurse should use rubber-tipped clamps to try to locate the leak by
clamping the tube momentarily at various points along its length.
A nurse is preparing to transport to radiology a patient who has a chest tube and closed-
chest wet-suction drainage system. The provider allows disconnecting the drainage system
the suction source during transportation. Which of the following must the nurse do when
detaching the suction source? ANS - Make sure the air vent is open
*Some closed-chest drainage systems and suction devices contain a vent from the water-
seal chamber. This allows the drainage unit to remain vented without suction. So, the nurse
should make sure this exit vent is open when disconnecting the suction source. Other
systems allow air to exit through the suction-control tubing. With these systems, the nurse
should keep the suction-control tubing uncapped and free from occlusion to prevent a
buildup of air inside the pleural cavity.
A nurse is caring for a patient who has a chest tube in place attached to a closed-chest
water-self drainage system following thoracic surgery. Which of the following strategies
should the nurse use to help promote comfort for this patient? ANS - Have the patient splint
the affected side during coughing
*It is essential for a patient with a chest tube to cough, not only to prevent postoperative
complications, but also to help drain the pleural space and expand the lungs. Splinting the
affected side, such as with a pillow, can help minimize the pain of coughing. The nurse
should also administer analgesia to help reduce the pain of coughing and other activities.
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