CC Ch. 21, Ch 21 Respiratory Care Modalities, PrepU Resp AH, MedSurg Chapter 21 Respiratory Care Modalities, Ch 21 - Respiratory Care Modalities, Ex. 4-Ch. 21 (Med Surg) Resp. Care Modalities

A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct?

"Before you do the exercise, I'll give you pain medication if you need it."

A client has been placed on a ventilator, and the spouse is visiting for the first time. The spouse begins to cry. The best statement by the nurse is

"Tell me what you are feeling."

When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods?

10 to 15 seconds

When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods? a) 30 to 35 seconds b) 20 to 25 seconds c) 0 to 5 seconds d) 10 to 15 seconds

10 to 15 seconds In general, the nurse should apply suction no longer than 10 to 15 seconds because hypoxia and dysrhythmias may develop, leading to cardiac arrest. Applying suction for 30 to 35 seconds is hazardous and may result in the patient's developing hypoxia, which can lead to dysrhythmias and, ultimately, cardiac arrest. Applying suction for 20 to 25 seconds is hazardous and may result in the patient's developing hypoxia, which can lead to dysrhythmias and, ultimately, cardiac arrest. Applying suction for 0 to 5 seconds would provide too little time for effective suctioning of secretions.

Which of the following ranges of water pressure identifies the amount of pressure within the endotracheal tube cuff that is believed to prevent both injury and aspiration?

15 to 20 mm Hg (Even though everything says 20-25) Usually the pressure is maintained at less than 25 cm water pressure to prevent injury and at more than 20 cm water pressure to prevent aspiration. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis, whereas low cuff pressure can increase the risk of aspiration pneumonia. A measure of 0 to 5 mm Hg or 10 to 15 mm Hg of water pressure would indicate that the cuff is underinflated. A measure of 30 to 35 mm Hg of water pressure would indicate that the cuff is overinflated.

Which of the following ranges of water pressure identifies the amount of pressure within the endotracheal tube cuff that is believed to prevent both injury and aspiration?

15-20

Which of the following is a correct endotracheal tube cuff pressure?

17mmhg

A patient with COPD requires oxygen administration. What method of delivery does the nurse know would be best for this patient?

A Venturi mask

A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for

A kink in the ventilator tubing

A patient with emphysema informs the nurse, "The surgeon will be removing about 30% of my lung so that I will not be so short of breath and will have an improved quality of life." What surgery does the nurse understand the surgeon will perform?

A lung volume reduction

Constant bubbling in the water seal of a chest drainage system indicates which of the following problems?

Air leak

The nurse is caring for a patient following a wedge resection. While the nurse is assessing the patient's chest tube drainage system, constant bubbling is noted in the water seal chamber. This finding indicates which of the following problems?

Air leak

A client has a sucking stab wound to the chest. Which action should the nurse take first?

Apply a dressing over the wound and tape it on three sides.

A nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority?

Assessing the client's respiratory status, orientation, and skin color

Which of the following ventilator modes provides full ventilatory support by delivering a present tidal volume and respiratory rate?

Assist control

For a client with an endotracheal (ET) tube, which nursing action is the most important?

Auscultating the lungs for bilateral breath sounds

A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs?

Auscultation

Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain?

Baseline arterial blood gas (ABG) levels

A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client?

By supplying a magic slate or similar device

A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client? a) By suctioning the client frequently b) By placing the call button under the client's pillow c) By supplying a magic slate or similar device d) By providing a tracheostomy plug to use for verbal communication

By supplying a magic slate or similar device The nurse should use a nonverbal communication method, such as a magic slate, note pad and pencil, and picture boards (if the client can't write or speak English). The physician orders a tracheostomy plug when a client is being weaned off a tracheostomy; it doesn't enable the client to communicate. The call button, which should be within reach at all times for all clients, can summon attention but doesn't communicate additional information. Suctioning clears the airway but doesn't enable the client to communicate.

A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse a) Consults with the physician about removing the client from the ventilator b) Continues assessing the client's respiratory status frequently c) Changes the setting on the ventilator to increase breaths to 14 per minute d) Contacts the respiratory therapy department to report the ventilator is malfunctioning

Continues assessing the client's respiratory status frequently The SIMV setting on a ventilator allows the client to breathe spontaneously with no assistance from the ventilator for those extra breaths. Data in the stem suggest that the ventilator is working correctly. The nurse would continue making frequent respiratory assessments of the client. There are not sufficient data to suggest the client could be removed from the ventilator. There is no reason to increase the ventilator's setting to 14 breaths per minute or to contact respiratory therapy to report the machine is not working properly.

A patient is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this patient?

Continuous positive airway pressure

The nurse is transporting a patient with chest tubes to a treatment room. The chest tube becomes disconnected and falls between the bed rail. What is the priority action by the nurse?

Cut the contaminated tip of the tube and insert a sterile connector and reattach.

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation?

ET suctioning

After suctioning a tracheostomy tube, the nurse assesses the client to determine the effectiveness of the suctioning. Which findings indicate that the airway is now patent?

Effective breathing at a rate of 16 breaths/minute through the established airway

A client is recovering from thoracic surgery needed to perform a right lower lobectomy. Which of the following is the most likely postoperative nursing intervention?

Encourage coughing to mobilize secretions.

A nurse is planning care for a client after a tracheostomy. One of the client's goals is to overcome verbal communication impairment. Which intervention should the nurse include in the care plan?

Encourage the client's communication attempts by allowing him time to select or write words

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation?

Endotracheal suctioning

A client is postoperative and prescribed an incentive spirometer (IS). The nurse instructs the client to:

Expect coughing when using the spirometer properly.

The nurse is preparing to perform chest physiotherapy (CPT) on a patient. Which of the following patient statements would indicate the procedure is contraindicated.

I just finished eating my lunch, I'm ready for my CPT now."

Which ventilator mode provides a combination of mechanically assisted breaths and spontaneous breaths? a) Assist-control b) Synchronized intermittent mandatory ventilation (SIMV) c) Pressure support d) Intermittent mandatory ventilation (IMV)

Intermittent mandatory ventilation (IMV) Intermittent mandatory ventilation (IMV) provides a combination of mechanically assisted breaths and spontaneous breaths. Assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate. SIMV delivers a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the patient can breathe spontaneously with no assistance from the ventilator for those extra breaths. Pressure support ventilation assists SIMV by applying a pressure plateau to the airway throughout the patient-triggered inspiration to decrease resistance within the tracheal tube and ventilator tubing.

A client is prescribed postural drainage because secretions are building in the superior segment of the lower lobes. Which is the best position to teach the client to use for postural drainage?

Lying prone

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?

Measuring & documenting the drainage in the collection chamber

Of the following oxygen administration devices, which has the advantage of providing high oxygen concentration? a) Catheter b) Venturi mask c) Face tent d) Non-rebreather mask

Non-rebreather mask The non-rebreather mask provides high oxygen concentration but it is usually poor fitting. The Venturi mask provides low levels of supplemental oxygen. The catheter is an inexpensive device that provides a variable fraction of inspired oxygen and may cause gastric distention. A face tent provides a fairly accurate fraction of inspired oxygen, but is bulky and uncomfortable. It would not be the device of choice to provide high oxygen concentration.

A client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery is most likely to reverse these manifestations?

Nonrebreather mask

The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia?

PaO2

Positive end-expiratory pressure (PEEP) therapy has which effect on the heart?

Reduced cardiac output

A nurse is weaning a client from mechanical ventilation. Which assessment finding indicates the weaning process should be stopped?

Runs of ventricular tachycardia

The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for:

Symmetry of the client's chest expansion

A client is prescribed postural drainage because secretions are accumulating in the upper lobes of the lungs. The nurse instructs the client to:

Take prescribed albuterol (Ventolin) before performing postural drainage.

A client in acute respiratory distress is brought to the emergency department. After endotracheal (ET) intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the ET tube, the nurse hyperventilates and hyperoxygenates the client. What is the rationale for these interventions?

They help prevent cardiac arrhythmias.

Which type of ventilator has a pre-sent volume of air to be delivered with each inspiration?

Volume cycled With volume-cycled ventilation, the volume of air to be delivered with each inspiration is present. Negative pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a present pressure, and then cycles off, and expiration occurs passively.

Which type of ventilator has a present volume of air to be delivered with each inspiration?

Volume-controlled

Which type of ventilator has a present volume of air to be delivered with each inspiration? a) Pressure-cycled b) Negative-pressure c) Time-cycled d) Volume-controlled

Volume-controlled With volume-controlled ventilation, the volume of air to be delivered with each inspiration is present. Negative pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a present pressure, and then cycles off, and expiration occurs passively.

Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. This therapy may be used for a client with:

a compromised skin graft

Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. This therapy may be used for a client with:

a compromised skin graft.

A nurse is attempting to wean a client after 2 days on the mechanical ventilator. The client has an endotracheal tube present with the cuff inflated to 15 mm Hg. The nurse has suctioned the client with return of small amounts of thin white mucus. Lung sounds are clear. Oxygen saturation levels are 91%. What is the priority nursing diagnosis for this client?

impaired gas exchange related to ventilator settings adjusted

Which of the following would indicate a decrease in pressure with mechanical ventilation?

increase in compliance

The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique?

instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes

In general, chest drainage tubes are not used for the patient undergoing

pneumonectomy

The nurse is caring for a patient who is scheduled for a lobectomy. Following the procedure, the nurse will plan care based on which of the following?

pt will return with 2 chest tubes

Fluctuations in the ______ are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respiration

water-seal compartment

A client who must begin oxygen therapy asks the nurse why this treatment is necessary? What would the nurse identify as the goals of oxygen therapy? Select all that apply.

• To reduce stress on the myocardium • To provide adequate transport of oxygen in the blood • To decrease the work of breathing

A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct?

"Before you do the exercise, I'll give you pain medication if you need it." The nurse should assess the client's pain level before the client does incentive spirometry exercises and administer pain medication as needed. Doing so helps the client take deeper breaths and help prevents atelectasis. The client should breathe in slowly and steadily, and hold his breath for 3 seconds after inhalation. The client should start doing incentive spirometry immediately after surgery and aim to do 10 incentive spirometry breaths every hour.

A client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. He's placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. The nursing goal should be to reduce the FIO2 to no greater than:

0.5.

The nurse is educating the patient in the use of a mini-nebulizer. What should the nurse encourage the patient to do? (Select all that apply.)

Hold the breath at the end of inspiration for a few seconds. Cough frequently. Frequently evaluate progress.

Which ventilator mode provides a combination of mechanically assisted breaths and spontaneous breaths?

Intermittent mandatory ventilation (IMV)

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?

Measuring and documenting the drainage in the collection chamber

Of the following oxygen administration devices, which has the advantage of providing high oxygen concentration?

Nonrebreather mask

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?

Partial pressure of arterial oxygen (PaO2)

The nurse is preparing to perform tracheostomy care on a patient with a newly inserted tracheostomy tube. Which of the following actions, if preformed by the nurse, indicates the need for further review of the procedure?

Places clean tracheostomy ties, and removes soiled ties after the new ties are in place

The nurse is teaching a postoperative client who had a coronary artery bypass graft about using the incentive spirometer. The nurse instructs the client to perform the exercise in the following order:

Sit in an upright position. Place the mouthpiece of the spirometer in the mouth. Breathe air in through the mouth. Hold breath for about 3 seconds. Exhale air slowly through the mouth.

The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient?

The patient is hypoxic from suctioning.

A patient in the ICU has been orally intubated and on mechanical ventilation for 2 weeks after having a severe stroke. What action does the nurse anticipate the physician will take now that the patient has been intubated for this length of time?

The patient will have an insertion of a tracheostomy tube.

A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

The system has an air leak.

A client who must begin oxygen therapy asks the nurse why this treatment is necessary? What would the nurse identify as the goals of oxygen therapy? Select all that apply.

To provide adequate transport of oxygen in the blood To decrease the work of breathing To reduce stress on the myocardium

Which of the following is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means

Venturi mask

Of the following oxygen administration devices, which has the advantage of providing high oxygen concentration?

non re breather mask

A nurse is caring for a client who has a tracheostomy tube and who is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by:

using the minimal-leak technique with cuff pressure less than 25 cm H2O.

The nurse is educating the patient in the use of a mini-nebulizer. What should the nurse encourage the patient to do? (Select all that apply.)

• Hold the breath at the end of inspiration for a few seconds. • Cough frequently. • Frequently evaluate progress.

The nurse is preparing to assist the health care provider with the removal of a patient's chest tube. Which of the following instructions will the nurse correctly give the patient?

"When the tube is being removed, take a deep breath, exhale, and bear down."

The nurse should monitor and document the amount and character of drainage every 2 hours. The nurse will notify the primary provider if drainage is _____ or greater.

50 mL/hr

Which of the following ventilator modes provides a combination of mechanically assisted breaths and spontaneous breaths?

Intermittent mandatory ventilation (IMV)

n general, chest drainage tubes are not indicated for a patient undergoing which of the following procedures?

Pneumonectomy

Which of the following is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means?

Venturi mask

Which of the following are indicators that a client is ready to be weaned from a ventilator? Select all that apply.

Vital capacity of 13 mL/kg Tidal volume of 8.5 mL/kg PaO2 of 64 mm Hg

Which type of ventilator has a pre-sent volume of air to be delivered with each inspiration?

Volume cycled

Which of the following is a potential complication of a low pressure in the endotracheal tube (ET) cuff?

aspiration pneumonia

A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse

continues assessing the pt respiratory status frequently

A client is postoperative and prescribed an incentive spirometer (IS). The nurse instructs the client to:

expect coughing when using the IS properly

A client who is undergoing thoracic surgery has a nursing diagnosis of "Impaired gas exchange related to lung impairment and surgery" on the nursing care plan. Which of the following nursing interventions would be appropriately aligned with this nursing diagnosis? Select all that apply.

• Monitor pulmonary status as directed and needed. • Regularly assess the client's vital signs every 2 to 4 hours. • Encourage deep breathing exercises

Arterial blood gases should be obtained at which timeframe following the initiation of continuous mechanical ventilation?

20 min

Which ventilator mode provides full ventilatory support by delivering a present tidal volume and respiratory rate?

Assist-control

A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned?

Auscultate the lung for adventitious sounds.

Which of the following is an adverse reaction that would require termination of the weaning process from the ventilator?

Blood pressure increase of 20 mm Hg

The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying?

Circulatory hypoxia

The nurse is caring for a patient with an endotracheal tube (ET). Which of the following nursing interventions is contraindicated?

Deflating the cuff routinely

A nurse is planning care for a client after a tracheostomy. One of the client's goals is to overcome verbal communication impairment. Which intervention should the nurse include in the care plan?

Encourage the client's communication attempts by allowing him time to select or write words.

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? a) Encouragement of coughing b) Use of a cooling blanket c) Incentive spirometry d) Endotracheal suctioning

Endotracheal suctioning Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.

The nurse should monitor a client receiving mechanical ventilation for which of the following complications?

Gastrointestinal hemorrhage

The nurse has instructed a patient on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which of the following?

Improve oxygen transport, induce a slow, deep breathing pattern, and assist the patient to control breathing

The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique?

Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes.

Of the following oxygen administration devices, which has the advantage of providing high oxygen concentration?

Non-rebreather mask

The nurse is teaching a postoperative client who had a coronary artery bypass graft about using the incentive spirometer. The nurse instructs the client to perform the exercise in the following order:

Sit in an upright position. Place the mouthpiece of the spirometer in the mouth. Breathe air in through the mouth. Hold breath for about 3 seconds. Exhale air slowly through the mouth.

A client has been placed on a ventilator, and the spouse is visiting for the first time. The spouse begins to cry. The best statement by the nurse is

Tell me what you are feeling

The nurse is caring for a patient who is scheduled for a lobectomy. Following the procedure, the nurse will plan care based on which of the following?

The patient will return to the nursing unit with two chest tubes

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes? a) Collection chamber b) Air-leak chamber c) Suction control chamber d) Water-seal chamber

Water-seal chamber Fluctuations in the water-seal compartment are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respirations. The air-leak meter — not chamber — detects air leaking from the pleural space. The collection chamber connects the chest tube from the client to the system. Drainage from the tube drains into and collects in a series of calibrated columns in this chamber. The suction control chamber provides the suction, which can be controlled to provide negative pressure to the chest. (less)

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes? a) Collection chamber b) Water-seal chamber c) Air-leak chamber d) Suction control chamber

Water-seal chamber Fluctuations in the water-seal compartment are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respirations. The air-leak meter — not chamber — detects air leaking from the pleural space. The collection chamber connects the chest tube from the client to the system. Drainage from the tube drains into and collects in a series of calibrated columns in this chamber. The suction control chamber provides the suction, which can be controlled to provide negative pressure to the chest. (less)

Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. This therapy may be used for a client with: a) a malignant tumor. b) a compromised skin graft. c) hyperthermia. d) pneumonia.

a compromised skin graft. A client with a compromised skin graft could benefit from hyperbaric oxygen therapy because increasing oxygenation at the wound site promotes wound healing. Hyperbaric oxygen therapy isn't indicated for malignant tumors, pneumonia, or hyperthermia.

The nurse is caring for a patient in the ICU who is receiving mechanical ventilation. Which of the following nursing measures are implemented in an effort to reduce the patient's risk of developing ventilator-associated pneumonia (VAP)?

cleaning the pts mouth with chlorhexidine daily

The nurse is caring for a patient with an endotracheal tube (ET). Which of the following nursing interventions is contraindicated?

deflating the cuff prior to removal

Which ventilator mode provides a combination of mechanically assisted breaths and spontaneous breaths?

intermittent mandatory ventilation

A patient is being mechanically ventilated with an oral endotracheal tube in place. The nurse observes that the cuff pressure is 25 mm Hg. The nurse is aware of what complications that can be caused by this pressure? (Select all that apply.)

• Pressure necrosis • Tracheal bleeding • Tracheal ischemia

A patient is brought into the emergency department with carbon monoxide poisoning after escaping a house fire. What should the nurse monitor this patient for?

Anemic hypoxia Anemic hypoxia is a result of decreased effective hemoglobin concentration, which causes a decrease in the oxygen-carrying capacity of the blood. It is rarely accompanied by hypoxemia. Carbon monoxide poisoning, because it reduces the oxygen-carrying capacity of hemoglobin, produces similar effects but is not strictly anemic hypoxia, because hemoglobin levels may be normal.

For a client with an endotracheal (ET) tube, which nursing action is the most important? a) Monitoring serial blood gas values every 4 hours b) Turning the client from side to side every 2 hours c) Providing frequent oral hygiene d) Auscultating the lungs for bilateral breath sounds

Auscultating the lungs for bilateral breath sounds For the client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although turning the client from side to side every 2 hours, monitoring serial blood gas values every 4 hours, and providing frequent oral hygiene are appropriate actions for this client, they're secondary to ensuring adequate oxygenation.

The nurse is caring for a patient being weaned from the mechanical ventilator. Which of the following patient findings would require the termination of the weaning process?

Blood pressure increase of 20 mm Hg from baseline

The nurse is caring for a patient following a thoracotomy. Which of the following findings requires immediate intervention by the nurse? a) Heart rate: 112 bpm b) Chest tube drainage of 190 mL/hr c) Moderate amounts of colorless sputum d) Pain of 5 on a 1 to 10 pain scale

Chest tube drainage of 190 mL/hr The nurse should monitor and document the amount and character of drainage every 2 hours. The nurse will notify the primary provider if drainage is 150 mL/hr or greater. The other findings are normal following a thoracotomy; no intervention is required.

A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education?

Encourage the patient to take approximately 10 breaths per hour, while awake.

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?

Manual Resuscitation bag

The nurse is assessing a patient with chest tubes connected to a drainage system. What should the first action be when the nurse observes excessive bubbling in the water seal chamber?

Notify the physician.

A client undergoes a tracheostomy after many failed attempts at weaning him from a mechanical ventilator. Two days after tracheostomy, while the client is being weaned, the nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first?

Suction the client, withdraw residual air from the cuff, and reinflate it.

A client with end-stage chronic obstructive pulmonary disease (COPD) requires bi-level positive airway pressure (BiPAP). While caring for the client, the nurse determines that bilateral wrist restraints are required to prevent compromised care. Which client care outcome is associated with restraint use in the client who requires BiPAP?

The client will maintain adequate oxygenation.

For a client with an endotracheal (ET) tube, which nursing action is the most important?

auscultate lungs for bilateral breath sounds

A nurse is caring for a client who was intubated because of respiratory failure. The client is now receiving mechanical ventilation with a preset tidal volume and number of breaths each minute. The client has the ability to breathe spontaneously between the ventilator breaths with no ventilator assistance. The nurse should document the ventilator setting as:

synchronized intermittent mandatory ventilation (SIMV)

A client with COPD has been receiving oxygen therapy for an extended period. What symptoms would be indicators that the client is experiencing oxygen toxicity? Select all that apply.

• Substernal pain • Dyspnea • Fatigue

The nurse is assigned the care of a patient with a chest tube. The nurse should ensure that which of the following items is kept at the patient's bedside?

A bottle of sterile water

A client who is undergoing thoracic surgery has a nursing diagnosis of "Impaired gas exchange related to lung impairment and surgery" on the nursing care plan. Which of the following nursing interventions would be appropriately aligned with this nursing diagnosis? Select all that apply

Monitor pulmonary status as directed and needed. Regularly assess the client's vital signs every 2 to 4 hours. Encourage deep breathing exercises.

A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?

Suction the client's artificial airway

A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?

Suction the client's artificial airway.

client has a sucking stab wound to the chest. Which action should the nurse take first?

apply a dressing and tape down 3 sides

After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must:

encourage coughing and deep breathing.

A nurse is caring for a client who was intubated because of respiratory failure. The client is now receiving mechanical ventilation with a preset tidal volume and number of breaths each minute. The client has the ability to breathe spontaneously between the ventilator breaths with no ventilator assistance. The nurse should document the ventilator setting as:

synchronized intermittent mandatory ventilation (SIMV).

The nurse is preparing to perform chest physiotherapy (CPT) on a patient. Which of the following patient statements would indicate the procedure is contraindicated. a) "I received my pain medication 10 minutes ago, let's do my CPT now." b) "I just finished eating my lunch, I'm ready for my CPT now." c) "I just changed into my running suit; we can do my CPT now." d) "I have been coughing all morning and am barely bringing anything up."

"I just finished eating my lunch, I'm ready for my CPT now." When performing CPT, the nurse ensures that the patient is comfortable, is not wearing restrictive clothing, and has not just eaten. The nurse gives medication for pain, as prescribed, before percussion and vibration and splints any incision and provides pillows for support, as needed. A goal of CPT is for the patient to be able to mobilize secretions; the patient who is having an unproductive cough is a candidate for CPT.

A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings?

84 mm Hg

A young male client has muscular dystrophy. His PaO2 is 42 mm Hg with a FiO2 of 80%. Which of the following treatments would be least invasive and most appropriate for this client?

Negative-pressure ventilator

A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

The system has an air leak

Which of the following ventilator modes provides full ventilatory support by delivering a present tidal volume and respiratory rate?

assist control

After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must:

encourage coughing and deep breathing

A client who is undergoing thoracic surgery has a nursing diagnosis of "Impaired gas exchange related to lung impairment and surgery" on the nursing care plan. Which of the following nursing interventions would be appropriately aligned with this nursing diagnosis? Select all that apply. a) Encourage deep breathing exercises. b) Monitor and record hourly intake and output. c) Regularly assess the client's vital signs every 2 to 4 hours. d) Maintain an open airway. e) Monitor pulmonary status as directed and needed.

• Monitor pulmonary status as directed and needed. • Regularly assess the client's vital signs every 2 to 4 hours. • Encourage deep breathing exercises. Interventions to improve the client's gas exchange include monitoring pulmonary status as directed and needed, assessing vital signs every 2 to 4 hours, and encouraging deep breathing exercises. Maintainin an open airway is appropriate for improving the client's airway clearance. Monitoring and recording hourly intake and output are essential interventions for ensuring appropriate fluid balance.

Which of the following are indicators that a client is ready to be weaned from a ventilator? Select all that apply. a) Tidal volume of 8.5 mL/kg b) Rapid/shallow breathing index of 112 breaths/min c) Vital capacity of 13 mL/kg d) FiO2 45% e) PaO2 of 64 mm Hg

• PaO2 of 64 mm Hg • Tidal volume of 8.5 mL/kg • Vital capacity of 13 mL/kg Weaning criteria for clients are as follows: Vital capacity 10 to 15 mL/kg; Maximum inspiratory pressure at least -20 cm H2; Tidal volume: 7 to 9 mL/kg; Minute ventilation: 6 L/min; Rapid/shallow breathing index below 100 breaths/min; PaO2 > 60 mm Hg; FiO2 < 40%

The nurse is preparing to assist the health care provider with the removal of a patient's chest tube. Which of the following instructions will the nurse correctly give the patient? a) "Exhale forcefully while the chest tube is being removed." b) "While the chest tube is being removed, raise your arms above your head." c) "During the removal of the chest tube, do not move because it will make the removal more painful." d) "When the tube is being removed, take a deep breath, exhale, and bear down."

"When the tube is being removed, take a deep breath, exhale, and bear down." When assisting in the chest tube's removal, instruct the patient to perform a gentle Valsalva maneuver or to breathe quietly. The chest tube is then clamped and quickly removed. Simultaneously, a small bandage is applied and made airtight with petrolatum gauze covered by a 4 × 4-inch gauze pad and thoroughly covered and sealed with nonporous tape. The other options are incorrect instructions for the patient.

The nurse is caring for a patient in the ICU who required emergent endotracheal (ET) intubation with mechanical ventilation. The nurse receives an order to obtain arterial blood gases (ABGs) following the procedure. The nurse recognizes that ABGs should be obtained at which timeframe following the initiation of mechanical ventilation?

20 minutes

A client in the intensive care unit has a tracheostomy with humidified oxygen being instilled through it. The client is expectorating thick yellow mucus through the tracheostomy tube frequently. The nurse

Assesses the client's tracheostomy and lung sounds every 15 minutes

Which ventilator mode provides full ventilatory support by delivering a present tidal volume and respiratory rate?

Assist-control Assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate. Intermittent mandatory ventilation (IMV) provides a combination of mechanically assisted breaths and spontaneous breaths. SIMV delivers a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the patient can breathe spontaneously with no assistance from the ventilator for those extra breaths.

A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse a) Continues assessing the client's respiratory status frequently b) Consults with the physician about removing the client from the ventilator c) Contacts the respiratory therapy department to report the ventilator is malfunctioning d) Changes the setting on the ventilator to increase breaths to 14 per minute

Continues assessing the client's respiratory status frequently The SIMV setting on a ventilator allows the client to breathe spontaneously with no assistance from the ventilator for those extra breaths. Data in the stem suggest that the ventilator is working correctly. The nurse would continue making frequent respiratory assessments of the client. There are not sufficient data to suggest the client could be removed from the ventilator. There is no reason to increase the ventilator's setting to 14 breaths per minute or to contact respiratory therapy to report the machine is not working properly.

The nurse is caring for a patient with an endotracheal tube (ET). Which of the following nursing interventions is contraindicated? a) Checking the cuff pressure every 6 to 8 hours b) Ensuring that humidified oxygen is always introduced through the tube c) Deflating the cuff prior to tube removal d) Deflating the cuff routinely

Deflating the cuff routinely Routine cuff deflation is not recommended because of the increased risk for aspiration and hypoxia. The cuff is deflated before the ET is removed. Cuff pressures should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tube.

A client is recovering from thoracic surgery needed to perform a right lower lobectomy. Which of the following is the most likely postoperative nursing intervention? a) Make sure that a thoracotomy tube is linked to open chest drainage. b) Restrict intravenous fluids for at least 24 hours. c) Assist with positioning the client on the right side. d) Encourage coughing to mobilize secretions.

Encourage coughing to mobilize secretions. The client is encouraged to cough frequently to mobilize secretions. The client will be placed in the semi-Fowler's position. Thoracotomy tubes are always attached to closed, sealed drainage to re-expand lung tissue and prevent pneumothorax. Restricting IV fluids in a client who is NPO while recovering from surgery would lead to dehydration. (less)

A nurse is attempting to wean a client after 2 days on the mechanical ventilator. The client has an endotracheal tube present with the cuff inflated to 15 mm Hg. The nurse has suctioned the client with return of small amounts of thin white mucus. Lung sounds are clear. Oxygen saturation levels are 91%. What is the priority nursing diagnosis for this client?

Impaired gas exchange related to ventilator setting adjustments

The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique? a) Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes. b) Administer bronchodilators and mucolytic agents following the sequence. c) Use aerosol sprays to deodorize the client's environment after postural drainage. d) Perform this measure with the client once a day.

Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes. Postural drainage is usually performed two to four times daily, before meals (to prevent nausea, vomiting, and aspiration) and at bedtime. Prescribed bronchodilators, water, or saline may be nebulized and inhaled before postural drainage to dilate the bronchioles, reduce bronchospasm, decrease the thickness of mucus and sputum, and combat edema of the bronchial walls. The nurse instructs the client to remain in each position for 10 to 15 minutes and to breathe in slowly through the nose and out slowly through pursed lips to help keep the airways open so that secretions can drain while in each position. If the sputum is foul-smelling, it is important to perform postural drainage in a room away from other patients or family members. (Deodorizers may be used to counteract the odor. Because aerosol sprays can cause bronchospasm and irritation, they should be used sparingly and with caution.)

A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?

Kinking of the ventilator tubing

A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm? a) A change in the oxygen concentration without resetting the oxygen level alarm b) Kinking of the ventilator tubing c) An ET cuff leak d) A disconnected ventilator tube

Kinking of the ventilator tubing Conditions that trigger the high-pressure alarm include kinking of the ventilator tubing, bronchospasm, pulmonary embolus, mucus plugging, water in the tube, and coughing or biting on the ET tube. The alarm may also be triggered when the client's breathing is out of rhythm with the ventilator. A disconnected ventilator tube or an ET cuff leak would trigger the low-pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would trigger the oxygen alarm, not the high-pressure alarm.

A patient with emphysema is placed on continuous oxygen at 2 L/min at home. Why is it important for the nurse to educate the patient and family that they must have No Smoking signs placed on the doors?

Oxygen supports combustion

A patient with emphysema is placed on continuous oxygen at 2 L/min at home. Why is it important for the nurse to educate the patient and family that they must have No Smoking signs placed on the doors?

Oxygen supports combustion.

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? a) Partial pressure of arterial carbon dioxide (PaCO2) b) Bicarbonate (HCO3-) c) Partial pressure of arterial oxygen (PaO2) d) pH

Partial pressure of arterial oxygen (PaO2) The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3-, and PaCO2.

Which of the following statements would not be considered an appropriate intervention for a patient with an ET tube?

Routine cuff deflation is recommended Routine cuff deflation is not recommended because of the increased risk for aspiration and hypoxia. The cuff is deflated before the endotracheal tube is removed. Cuff pressures should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tube.

The client is postoperative for a total laryngectomy and has recovered from anesthesia. The client's respirations are 32 breaths/minute, blood pressure is 102/58, and pulse rate is 104 beats/minute. Pulse oximetry is 90%. The client is receiving humidified oxygen. To aid in the client's respiratory status, the nurse places the client in

Semi-Fowlers

A client with COPD has been receiving oxygen therapy for an extended period. What symptoms would be indicators that the client is experiencing oxygen toxicity? Select all that apply.

Substernal pain Dyspnea Fatigue

The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient? a) The patient is in a hypermetabolic state. b) The patient is hypoxic from suctioning. c) The patient is having a myocardial infarction. d) The patient is having a stress reaction.

The patient is hypoxic from suctioning. Apply suction while withdrawing and gently rotating the catheter 360 degrees (no longer than 10-15 seconds). Prolonged suctioning may result in hypoxia and dysrhythmias, leading to cardiac arrest.

A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? a) The client has a pneumothorax. b) The system has an air leak. c) The chest tube is obstructed. d) The system is functioning normally.

The system has an air leak. Constant bubbling in the water-seal chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the fluid would stop fluctuating in the water-seal chamber. (less)

A patient is being mechanically ventilated in the ICU. The ventilator alarms begin to sound. The nurse should complete which of the following actions first? a) Notify the respiratory therapist. b) Troubleshoot to identify the malfunction. c) Reposition the endotracheal (ET) tube. d) Manually ventilate the patient.

Troubleshoot to identify the malfunction. The nurse should first immediately attempt to identify and correct the problem and, if the problem cannot be identified and/or corrected, the patient must be manually ventilated with an Ambu bag. The respiratory therapist may be notified, but this is not the first action by the nurse. The nurse should not reposition the ET tube as a first response to an alarm.

A client with supraglottic cancer undergoes a partial laryngectomy. Postoperatively, a cuffed tracheostomy tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to: a) hold the breath as the cuff is being reinflated. b) take a deep breath as the nurse deflates the cuff. c) cough as the cuff is being deflated. d) exhale deeply as the nurse reinflates the cuff.

cough as the cuff is being deflated. The nurse should instruct the client to cough during cuff deflation. If the client can't cough, the nurse should perform suctioning to prevent aspiration of secretions. Because the cuff should be deflated during expiration, the client shouldn't take a deep breath as the nurse deflates the cuff. Likewise, because the cuff is reinflated during inspiration, the client shouldn't hold the breath or exhale deeply during reinflation.

After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must: a) report fluctuations in the water-seal chamber. b) milk the chest tube every 2 hours. c) clamp the chest tube once every shift. d) encourage coughing and deep breathing.

encourage coughing and deep breathing. When caring for a client who's recovering from a thoracotomy, the nurse should encourage coughing and deep breathing to prevent pneumonia. Fluctuations in the water-seal chamber are normal. Clamping the chest tube could cause a tension pneumothorax. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage.

A nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is:

keeping his airway patent.

A young male client has muscular dystrophy. His PaO2 is 42 mm Hg with a FiO2 of 80%. Which of the following treatments would be least invasive and most appropriate for this client?

neg pressure ventilator This client needs ventilatory support. His PaO2 is low despite receiving a high dose of oxygen. The iron lung or drinker respiratory tank is an example of a negative-pressure ventilator. This type of ventilator is used mainly with chronic respiratory failure associated with neurological disorders, such as muscular dystrophy. It does not require intubation of the client. The most common ventilator is the positive-pressure ventilator, but this involves intubation with an endotracheal tube or tracheostomy. CPAP is used for obstructive sleep apnea. Bi-PAP is used for those with severe COPD or sleep apnea who require ventilatory assistance at night.

A nurse is caring for a client who has a tracheostomy tube and who is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by:

using the minimal-leak technique with cuff pressure less than 25 cm H2O. To prevent tracheal dilation, a minimal-leak technique should be used and the pressure should be kept at less than 25 cm H2O. Suctioning is vital but won't prevent tracheal dilation. Use of a cuffed tube alone won't prevent tracheal dilation. The tracheostomy shouldn't be plugged to prevent tracheal dilation. This technique is used when weaning the client from tracheal support.

The nurse is using an in-line suction kit to suction a patient who is intubated and on a mechanical ventilator. What benefits does inline suction have for the patient? (Select all that apply.)

• Decreases hypoxemia • Decreases patient anxiety • Sustains positive end expiratory pressure (PEEP)

The nurse is preparing to perform chest physiotherapy (CPT) on a patient. Which of the following patient statements would indicate the procedure is contraindicated.

"I just finished eating my lunch, I'm ready for my CPT now."

The nurse is educating the patient in the use of a mini-nebulizer. What should the nurse encourage the patient to do? (Select all that apply.)

• Cough frequently. • Hold the breath at the end of inspiration for a few seconds. • Frequently evaluate progress.

A client with COPD has been receiving oxygen therapy for an extended period. What symptoms would be indicators that the client is experiencing oxygen toxicity? Select all that apply.

• Dyspnea • Substernal pain • Fatigue

A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse

Continues assessing the client's respiratory status frequently

The nurse received a client from the post-anesthesia care unit (PACU) who has a chest tube to a closed drainage system. Report from the PACU nurse included drainage in the chest tube at 80 mL of bloody fluid. Fifteen minutes after transfer from the PACU, the chest tube indicates drainage as pictured. The client is reporting pain at "8" on a scale of 0 to 10. The first action of the nurse is to:

Assess pulse and blood pressure.

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation?

Endotracheal

In general, chest drainage tubes are not used for the patient undergoing

pneumonectomy.

A client with COPD has been receiving oxygen therapy for an extended period. What symptoms would be indicators that the client is experiencing oxygen toxicity? Select all that apply. a) Substernal pain b) Fatigue c) Dyspnea d) Bradycardia e) Mood swings

• Dyspnea • Substernal pain • Fatigue Oxygen toxicity can occur when clients receive too high a concentration of oxygen for an extended period. Symptoms include dyspnea, substernal pain, restlessness, fatigue, and progressive respiratory difficulty. Bradycardia and mood swings are not symptoms of oxygen toxicity.

A client who must begin oxygen therapy asks the nurse why this treatment is necessary? What would the nurse identify as the goals of oxygen therapy? Select all that apply.

• To provide adequate transport of oxygen in the blood • To decrease the work of breathing • To reduce stress on the myocardium

Arterial blood gases should be obtained at which timeframe following the initiation of continuous mechanical ventilation?

20 minutes

A client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for:

5 to 20 minutes.

A client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for: a) 30 to 40 minutes. b) 5 to 20 minutes. c) 15 to 60 seconds. d) 45 to 60 minutes.

5 to 20 minutes. Initially, the nurse should plug the opening in the tracheostomy tube for 5 to 20 minutes, then gradually lengthen this interval according to the client's respiratory status. A client who doesn't require continuous mechanical ventilation already is breathing without assistance, at least for short periods; therefore, plugging the opening of the tube for only 15 to 60 seconds wouldn't be long enough to reveal the client's true tolerance to the procedure. Plugging the opening for more than 20 minutes would increase the risk of acute respiratory distress because the client requires an adjustment period to start breathing normally.

A young man incurred a spontaneous pneumothorax. The physician has just inserted a chest tube and has prescribed suction set at 20 cm of water. The nurse instills the fluid to this level in the appropriate chamber. Mark the level of fluid on the appropriate chamber of the closed drainage system.

A (below the 2002 date number on picture)

A client has a sucking stab wound to the chest. Which action should the nurse take first? a) Prepare to start an I.V. line. b) Apply a dressing over the wound and tape it on three sides. c) Prepare a chest tube insertion tray. d) Draw blood for a hematocrit and hemoglobin level.

Apply a dressing over the wound and tape it on three sides. The nurse should immediately apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line.

A client on long-term mechanical ventilation becomes very frustrated when he tries to communicate. Which intervention should the nurse perform to assist the client?

Ask the client to write, use a picture board, or spell words with an alphabet board.

Which of the following is a potential complication of a low pressure in the ET cuff?

Aspiration pneumonia

Which of the following is a potential complication of a low pressure in the endotracheal tube (ET) cuff?

Aspiration pneumonia

The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying? a) Hypoxic hypoxia b) Circulatory hypoxia c) Histotoxic hypoxia d) Anemic hypoxia

Circulatory hypoxia Given this patient's vital signs, he appears to be in shock. Circulatory hypoxia is hypoxia resulting from inadequate capillary circulation. It may be caused by decreased cardiac output, local vascular obstruction, low-flow states such as shock, or cardiac arrest. Although tissue partial pressure of oxygen (PO2) is reduced, arterial oxygen (PaO2) remains normal. Circulatory hypoxia is corrected by identifying and treating the underlying cause. (less)

The nurse is transporting a patient with chest tubes to a treatment room. The chest tube becomes disconnected and falls between the bed rail. What is the priority action by the nurse? a) Immediately reconnect the chest tube to the drainage apparatus. b) Cut the contaminated tip of the tube and insert a sterile connector and reattach. c) Clamp the chest tube close to the connection site. d) Call the physician.

Cut the contaminated tip of the tube and insert a sterile connector and reattach. If the patient is lying on a stretcher and must be transported to another area, place the drainage system below the chest level. If the tubing disconnects, cut off the contaminated tips of the chest tube and tubing, insert a sterile connector in the cut ends, and reattach to the drainage system. Do not clamp the chest tube during transport. (less)

Which type of oxygen therapy includes the administration of oxygen at pressure greater than 1 atmosphere?

Hyperbaric

A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition?

Hypoxia

A nurse is caring for a client after a thoracotomy for a lung mass. Which nursing diagnosis should be the first priority?

Impaired gas exchange

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?

Manual resuscitation bag

A patient has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the patient complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect?

Oxygen toxicity

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? a) Partial pressure of arterial oxygen (PaO2) b) Bicarbonate (HCO3-) c) Partial pressure of arterial carbon dioxide (PaCO2) d) pH

Partial pressure of arterial oxygen (PaO2) The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3-, and PaCO2 (less)

Which of the following statements would not be considered an appropriate intervention for a patient with an ET tube?

Routine cuff deflation is recommended

A nurse is weaning a client from mechanical ventilation. Which assessment finding indicates the weaning process should be stopped? a) Runs of ventricular tachycardia b) Oxygen saturation of 93% c) Respiratory rate of 16 breaths/minute d) Blood pressure increase from 120/74 mm Hg to 134/80 mm Hg

Runs of ventricular tachycardia Ventricular tachycardia indicates that the client isn't tolerating the weaning process. The weaning process should be stopped before lethal ventricular arrhythmias occur. A respiratory rate of 16 breaths/minute and an oxygen saturation of 93% are normal findings. Although the client's blood pressure has increased, it hasn't increased more than 20% over baseline, which would indicate that the client isn't tolerating the weaning process.

Question: The nurse is teaching a postoperative client who had a coronary artery bypass graft about using the incentive spirometer. The nurse instructs the client to perform the exercise in the following order:

Sit in an upright position. Place the mouthpiece of the spirometer in the mouth. Breathe air in through the mouth. Hold breath for about 3 seconds. Exhale air slowly through the mouth.

The nurse is caring for a patient who is scheduled for a lobectomy. Following the procedure, the nurse will plan care based on which of the following? a) The patient will return from surgery with no drainage tubes. b) The patient will require mechanical ventilation following surgery. c) The patient will return to the nursing unit with two chest tubes. d) The patient will require sedation until the chest tube (s) are removed.

The patient will return to the nursing unit with two chest tubes. The nurse should plan for the patient to return to the nursing unit with two chest tubes intact. During a lobectomy, the lobe is removed, and the remaining lobes of the lung are re-expanded. Usually, two chest catheters are inserted for drainage. The upper tube is for air removal; the lower one is for fluid drainage. Sometimes, only one catheter is needed. The chest tube is connected to a chest drainage apparatus for several days.

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes?

Water-seal chamber

A client with supraglottic cancer undergoes a partial laryngectomy. Postoperatively, a cuffed tracheostomy tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to:

cough as the cuff is being deflated.