You are caring for a patient who just had a chest tube placed. Which of the following would you want to report to the healthcare provider immediately?
The patient's oxygen saturation which is 100% on room air
>200 ml drainage in first hour
The patient is complaining of mild pain at the chest tube insertion site
A temperature of 99.9 F
The Correct Answer is B
A. The patient's oxygen saturation which is 100% on room air: A saturation of 100% indicates adequate oxygenation and is reassuring. There is no immediate concern, so it does not require urgent reporting.
B. >200 ml drainage in first hour: Excessive chest tube drainage, particularly more than 200 ml in an hour, may indicate active bleeding or hemorrhage. This is a potentially life-threatening complication that requires immediate notification of the healthcare provider for rapid intervention.
C. The patient is complaining of mild pain at the chest tube insertion site: Mild pain is expected after chest tube placement and can typically be managed with analgesics. It does not represent an emergency and is monitored routinely.
D. A temperature of 99.9 F: A slightly elevated temperature is not uncommon post-procedure and does not indicate a critical complication. Fever monitoring should continue, but this finding does not necessitate immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. To provide a certain volume of air to patient: Delivering a specific tidal volume is controlled by the ventilator’s volume settings, not by PEEP. PEEP functions to maintain alveolar pressure after expiration rather than to regulate the amount of air delivered with each breath.
B. To increase volume of air left in lungs at the end of expiration in order to help open up collapsed alveoli: PEEP prevents alveolar collapse by maintaining positive pressure in the lungs at the end of expiration. This helps improve gas exchange, increase functional residual capacity, and enhance oxygenation, especially in conditions like ARDS or pulmonary edema.
C. To increase patient’s respiratory rate: The respiratory rate is controlled by ventilator frequency settings, not by PEEP. Increasing PEEP does not alter the number of breaths delivered per minute but rather the pressure maintained after exhalation.
D. To decrease patient’s respiratory rate: PEEP does not directly influence respiratory rate; it affects oxygenation and alveolar stability. Any change in respiratory rate must be adjusted through the ventilator’s rate settings or sedation management, not by altering PEEP levels.
Correct Answer is A
Explanation
A. Oral care: Regular oral hygiene helps reduce the bacterial load in the mouth and oropharynx, which can prevent aspiration of pathogens into the lungs. This is one of the most effective nursing interventions to reduce the risk of ventilator-associated pneumonia.
B. Ordering antibiotics for the patient: Nurses do not independently order antibiotics, and prophylactic antibiotics are not routinely recommended for VAP prevention. Unnecessary antibiotic use can lead to resistance and other complications.
C. Giving patient cough medications: Suppressing cough in ventilated patients is not recommended, as effective coughing helps clear secretions. Cough medications do not prevent VAP and may interfere with natural airway clearance.
D. Monitoring patient for a fever and letting the healthcare provider know if there is one: While monitoring for infection is important, this is a reactive intervention rather than a preventive measure. Oral care and other hygiene measures directly reduce VAP risk before infection occurs.
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