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Questions and Answers
What is the primary mechanism that causes a tension pneumothorax?
Which symptom is NOT typically associated with a tension pneumothorax?
What condition results from the accumulation of blood in the pleural space?
What is the recommended action for an open wound to prevent air entry?
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What is a common cause for chylothorax?
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In the case of a penetrating wound, what should be done with the object causing the injury?
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What is a typical finding upon percussion of a patient with pneumothorax?
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What position should a patient be in to promote drainage when managing a chest tube?
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Which of the following nursing diagnoses is most relevant for a patient with a large pneumothorax?
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What indicates that a chest tube system may have a leak?
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What immediate treatment is required for a tension pneumothorax?
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Which is an expected outcome after successful management of a pneumothorax?
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Which of these can lead to hypoxia in a tension pneumothorax case?
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What should be documented regularly within the client's care involving a chest tube?
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What does the absence of tidaling in the water seal chamber suggest?
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How should a client presenting with subcutaneous emphysema be managed?
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What should be avoided to prevent complications like tension pneumothorax?
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Which equipment is essential to have for managing emergencies with a chest tube?
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What is a key safety measure regarding the chest tube drainage system?
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Which activity is advisable for clients on bedrest to prevent respiratory complications?
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In mechanical ventilation, what does Assist-Control (AC) ventilation provide?
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What is the purpose of Positive End-Expiratory Pressure (PEEP) in ventilation?
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What characterizes High-Frequency Oscillatory Ventilation (HFOV)?
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During client transportation, it is important to:
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What is the primary purpose of endotracheal intubation?
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Which of the following is NOT a contraindication for endotracheal intubation?
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What is a common cause for a high-pressure ventilator alarm?
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What is the purpose of Rapid-Sequence Intubation (RSI)?
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How often should oral care be performed to prevent Ventilator-Associated Pneumonia (VAP)?
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Which action is appropriate when a low-pressure alarm sounds?
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What should a nurse monitor after the intubation process?
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Which of the following actions is NOT included in the nursing responsibilities for mechanical ventilation care?
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Which factor could limit the use of noninvasive positive pressure ventilation (NPPV)?
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What is the function of PEEP in mechanical ventilation?
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What should be the typical setting for respiratory rate in mechanical ventilation?
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What is a key nursing action when setting up NPPV equipment?
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What initial actions should be taken in response to endotracheal tube displacement?
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What is a possible complication of using noninvasive positive pressure ventilation (NPPV)?
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What monitoring is essential for a patient on NPPV?
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When adjusting a low-pressure alarm, what might the nurse need to do?
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Study Notes
Rib Fractures and Chest Trauma
- Rib fractures can result from penetrating (e.g., stab wounds) or blunt trauma to the chest.
- Trauma can breach the pleura, allowing air into the pleural cavity, leading to lung collapse.
Tension Pneumothorax
- Occurs when air enters the pleural cavity but cannot escape, may follow penetrating wounds or mechanical ventilation.
- Increased pressure from trapped air causes lung collapse and mediastinal shift, impacting heart and great vessel function.
- Medical emergency requiring needle or chest tube insertion to decompress the pleural cavity.
- Symptoms include severe respiratory distress, tracheal deviation, decreased cardiac output, and potential cardiovascular collapse.
Hemothorax
- Blood accumulation in the pleural space can lead to lung collapse.
- Symptoms involve chest pain, shallow rapid breathing, and possible wheezing or coughing.
- Traumatic injury is a common cause.
Chylothorax
- Accumulation of chyle (lipid-rich fluid) in the pleural cavity due to thoracic duct damage.
- Types include spontaneous, traumatic, and idiopathic (unknown cause).
Nursing Diagnosis for Pneumothorax
- Assessment: Observe for sudden chest pain, shortness of breath, tachycardia, dyspnea, respiratory distress, and hyperresonance on percussion.
- Diagnosis may include acute pain, impaired gas exchange, ineffective breathing pattern, and ineffective tissue perfusion.
Treatment & Management
- Emergency: Apply an occlusive dressing for open wounds, stabilize penetrating injuries, assess oxygen levels, elevate the head of the bed.
- Long-term management could involve chest tube insertion or surgery, with education on risk factors and smoking cessation.
Expected Outcomes
- Goal to establish effective respiratory patterns and normal arterial blood gases.
- Monitor for cyanosis absence and manageable pain levels.
- Evaluation through X-ray confirmation of pneumothorax resolution, normal respiratory patterns, and adequate tissue perfusion.
Nursing Management of a Client with a Chest Tube
- Position in upright Fowler's position for optimal drainage.
- Comprehensive assessments include monitoring respiratory and heart rates, breath sounds, and signs of infection at the insertion site.
- Ensure drainage system is below the chest and monitor drainage characteristics.
Key Safety Measures for Chest Tube
- Maintain drainage system below chest level and check for kinks or obstructions.
- Secure tubing connections with tape and ensure water seal chamber is filled properly.
Client Activity Management
- Encourage position changes and use of incentive spirometry to prevent respiratory complications.
- Educate ambulating clients on protecting the drainage system during movement.
Mechanical Ventilation Terminology
- Assist-Control (AC) Ventilation delivers preset tidal volume and rate; used for sedated clients.
- Endotracheal intubation is critical for securing the airway in emergencies.
- Rapid-Sequence Intubation involves rapid IV administration of sedative and paralytic.
Ventilator Management
- Monitor client response and adjust ventilator settings as needed.
- Prevent ventilator-associated pneumonia with appropriate positioning, oral care, and suctioning.
Handling Ventilator Alarms
- High-pressure alarms indicate secretions or coughing; low-pressure alarms suggest disconnections.
- Apnea alarms may signal respiratory arrest; interventions include providing oxygen and assessing ETT position.
Extubation and Weaning
- Weaning involves gradual ventilator support reduction through spontaneous breathing trials.
- Post-extubation monitoring focuses on oxygenation, breathing rate, and gas levels.
Noninvasive Positive Pressure Ventilation (NPPV) Complications
- Potential issues include claustrophobia, apnea, neuromuscular disease, facial trauma, and aspiration risk.
- Nursing actions involve collaboration with respiratory therapy, equipment setup, and monitoring of breathing patterns and mask fit.
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Description
Explore the causes and effects of tension pneumothorax, a serious condition resulting from traumatic injuries such as rib fractures or penetrating chest wounds. This quiz covers the underlying mechanisms that lead to air accumulation in the pleural cavity and subsequent lung collapse.
