Chapter 21

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"

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

10-15 seconds

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 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

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

baseline arterial blood gas levels (ABGs)

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 ten breaths per hour while awake

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

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 10-15 minutes

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.)

-tracheal ischemia -tracheal bleeding -tracheal necrosis

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 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)

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

air leak

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

auscultating the lungs for bilateral breath sounds

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

continue assessing the client's respiratory status frequently

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 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 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 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 patient's artificial airway

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

venturi mask

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

volume-controlled