A nurse is caring for a patient on mechanical ventilation and finds the patient agitated and thrashing about.
What action by the nurse is most appropriate?

Sedate the patient immediately.

Reassure the patient that they are safe.

Restrain the patient's hands.

Assess the cause of agitation.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Sedating the patient immediately without assessing the cause of agitation is a dangerous action. Agitation could be a sign of a serious, reversible condition such as hypoxia, a disconnected ventilator circuit, or a pneumothorax. Masking these symptoms with sedation could delay the diagnosis and treatment of a life-threatening problem. The priority is to first investigate the cause of the patient's distress to ensure their safety and provide appropriate, targeted care.

Choice B rationale

Reassuring the patient is a good practice, but it is not the most appropriate initial action. While it may help calm the patient, it does not address potential underlying physiological causes for the agitation, such as hypoxemia or a ventilator malfunction. The priority is to first perform a comprehensive physical assessment and a check of the ventilator to rule out critical, life-threatening issues before attempting to address the patient's emotional state with verbal reassurance.

Choice C rationale

Restraining the patient should be a last resort after other interventions have failed to address the cause of agitation. It can increase the patient's anxiety and is a significant safety and legal concern. Restraints can also obstruct the nurse's ability to assess the patient thoroughly and may worsen the patient's condition if the underlying cause is not identified. The priority is always to determine and treat the source of the agitation first.

Choice D rationale

Agitation in a ventilated patient is a critical sign that something is wrong, and it requires immediate investigation to determine the cause. The nurse should systematically assess the patient, starting with the ventilator circuit for disconnections or alarms, checking vital signs for hypoxia or hypotension, and auscultating lung sounds. This assessment-first approach ensures that serious, reversible causes are identified and addressed promptly, preventing harm to the patient.

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Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

This is an expected finding. Following a thoracotomy, a certain amount of drainage is anticipated from the chest tube as a result of inflammation and bleeding from the surgical site. A drainage volume of 50 mL is considered normal in the immediate postoperative period and should be monitored closely. However, if the drainage exceeds 100 mL/hour, it could indicate hemorrhage and requires immediate notification of the healthcare provider.

Choice B rationale

This is a correct principle of chest tube management. The drainage system must be kept below the level of the patient's chest to prevent fluid from flowing back into the pleural cavity. The principle of gravity ensures that air and fluid from the pleural space continue to drain into the collection chamber, which is essential for re-expanding the lung and maintaining negative intrapleural pressure.

Choice C rationale

This is an essential component of chest tube care. An occlusive dressing is applied over the chest tube insertion site to prevent air from entering the pleural space from the outside. This dressing ensures that the closed drainage system remains airtight and prevents a pneumothorax, which could cause the lung to collapse again. The dressing must be kept intact and taped on all sides.

Choice D rationale

Excessive bubbling in the water seal chamber is an unexpected finding. The water seal chamber should normally have gentle tidaling (fluctuations) with respirations, indicating changes in intrapleural pressure. Constant, vigorous bubbling suggests a significant air leak, which could be from the insertion site, tubing, or within the chest, indicating a persistent pneumothorax or a problem with the system. It needs to be investigated.

Choice E rationale

Vigorous bubbling in the suction control chamber is an incorrect finding. The suction control chamber should have gentle, continuous bubbling to indicate that the appropriate level of suction is being applied. Vigorous or turbulent bubbling is inefficient, causes the water to evaporate quickly, and does not increase the amount of suction applied to the chest. It simply indicates excessive airflow

A. Use nonverbal pain assessment tools. B. Assess the patient for sedation needs. C. Get family permission for restraints. D. Provide frequent oral care per protocol.

Correct Answer is D

Explanation

Choice A rationale

Assessing for pain, especially using nonverbal tools, requires clinical judgment and the ability to interpret physiological and behavioral cues. This is a complex nursing skill that involves analysis and critical thinking to determine the appropriate response. Therefore, it is a task that cannot be delegated to UAP, whose scope of practice focuses on basic care and activities of daily living, not complex patient assessments or clinical judgments.

Choice B rationale

Assessing a patient's sedation needs involves evaluating their level of consciousness, response to stimuli, and other clinical indicators to determine if they are adequately sedated or if adjustments are necessary. This is a skilled nursing assessment requiring advanced knowledge of pharmacology and patient physiology. UAP are not trained to perform these assessments and cannot make the clinical judgments required for adjusting or monitoring sedation levels, making delegation unsafe and outside their scope of practice.

Choice C rationale

Obtaining consent, including permission for restraints, is a legal and ethical responsibility of the registered nurse or other licensed healthcare provider. This process involves educating the family about the risks and benefits and ensuring their understanding. It requires a detailed conversation and is beyond the scope of a UAP, who do not have the legal authority or clinical expertise to engage in discussions about informed consent for medical interventions, even non-pharmacological ones.

Choice D rationale

Providing frequent oral care is a supportive and hygienic task that is within the UAP's scope of practice. It involves performing a procedure that follows an established protocol and does not require complex clinical assessment or decision-making. Oral care is crucial for mechanically ventilated patients to prevent ventilator-associated pneumonia by reducing the bacterial load in the mouth, and it is an appropriate task for a UAP to perform under nurse supervision

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A nurse is caring for a patient on mechanical ventilation and finds the patient agitated and thrashing about. What action by the nurse is most appropriate?

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A nurse is caring for a patient on mechanical ventilation and finds the patient agitated and thrashing about.
What action by the nurse is most appropriate?