Chapter 21: Respiratory Care Modalities
A nurse is caring for a client with COPD who needs teaching on pursed-lip breathing. Place the steps in order in which the nurse will instruct the client. 1 "Inhale through your nose." 2 "Slowly count to 7." 3 "Slowly count to 3." 4 "Exhale slowly through pursed lips."
"Inhale through your nose." "Slowly count to 3." "Exhale slowly through pursed lips." "Slowly count to 7." Explanation: Pursed-lip breathing is a technique used to prolong exhalation by propping the airways open and promoting the removal of trapped air and carbon dioxide. The nurse should instruct the client to first inhale through the nose to a slow count of 3. Next, the client should exhale slowly through pursed lips for a count of 7.
When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for how long? 10 to 15 seconds 0 to 5 seconds 20 to 25 seconds 30 to 35 seconds
10 to 15 seconds Explanation: In general, the nurse should apply suction no longer than 10 to 15 seconds. Applying suction for 20-25 or 30-35 seconds is hazardous and may result in the development of hypoxia, which can lead to dysrhythmias and, ultimately, cardiac arrest. Applying suction for 0-5 seconds would provide too little time for effective suctioning of secretions.
Arterial blood gases should be obtained how often after initiating continuous mechanical ventilation? 20 minutes 25 minutes 10 minutes 15 minutes
20 minutes Explanation: ABGs should be obtained to measure carbon dioxide partial pressure (PaCO2), pH, and PaO2 after 20 minutes of continuous mechanical ventilation.
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 120 mm Hg 45 mm Hg 58 mm Hg
84 mm Hg Explanation: In general, clients with respiratory conditions are given oxygen therapy only to increase the arterial oxygen pressure (PaO2) back to the client's normal baseline, which may vary from 60 to 95 mm Hg
A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for Malfunction of the alarm button Higher than normal endotracheal cuff pressure A cut or slice in the tubing from the ventilator A kink in the ventilator tubing
A kink in the ventilator tubing Explanation: One event that could cause the ventilator's peak-airway-pressure alarm to sound is a kink in the ventilator tubing. After making this and other assessments without correction, then it could be a malfunction of the alarm button. Higher than normal endotracheal cuff pressure could cause client tissue damage but would not make the ventilator alarms sound. A cut or slice in the tubing from the ventilator would result in decreased pressure.
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? Have the patient cough. Assess the CO2 level to determine if the patient requires suctioning. Have the patient inform the nurse of the need to be suctioned. Auscultate the lung for adventitious sounds.
Auscultate the lung for adventitious sounds. Explanation: When a tracheostomy or endotracheal tube is in place, it is usually necessary to suction the patient's secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are obviously present. Unnecessary suctioning can initiate bronchospasm and cause mechanical trauma to the tracheal mucosa.
A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs? Inspection Chest X-ray Arterial blood gas (ABG) levels Auscultation
Auscultation Explanation: The nurse should assess breath sounds before doing postural drainage to determine the areas that need draining. Inspection, chest X-rays, and ABG levels are all assessment parameters that give good information about respiratory function but aren't necessary to determine lung areas requiring postural drainage.
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? Hypoxic hypoxia Anemic hypoxia Histotoxic hypoxia Circulatory hypoxia
Circulatory hypoxia Explanation: 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.
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 Contacts the respiratory therapy department to report the ventilator is malfunctioning Consults with the physician about removing the client from the ventilator Continues assessing the client's respiratory status frequently Changes the setting on the ventilator to increase breaths to 14 per minute
Continues assessing the client's respiratory status frequently Explanation: 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 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? Have the patient lie in a supine position during the use of the spirometer. Encourage the patient to try to stop coughing during and after using the spirometer. Encourage the patient to take approximately 10 breaths per hour, while awake. Inform the patient that using the spirometer is not necessary if the patient is experiencing pain.
Encourage the patient to take approximately 10 breaths per hour, while awake. Explanation: The patient should be instructed to perform the procedure approximately 10 times in succession, repeating the 10 breaths with the spirometer each hour during waking hours. The patient should assume a semi-Fowler's position or an upright position before initiating therapy, not be supine. Coughing during and after each session is encouraged, not discouraged. The patient should Splint the incision when coughing postoperatively. The patient should still use the spirometer when in pain.
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. Administer bronchodilators and mucolytic agents following the sequence. Perform this measure with the client once a day. Use aerosol sprays to deodorize the client's environment after postural drainage.
Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes. Explanation: 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? A change in the oxygen concentration without resetting the oxygen level alarm An ET cuff leak Kinking of the ventilator tubing A disconnected ventilator circuit
Kinking of the ventilator tubing Explanation: 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 circuit 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.
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? Stripping the chest tube every hour Maintaining continuous bubbling in the water-seal chamber Keeping the collection chamber at chest level Measuring and documenting the drainage in the collection chamber
Measuring and documenting the drainage in the collection chamber Explanation: The nurse should regularly measure and document the amount of chest tube drainage to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected. The nurse should keep the collection chamber below chest level to allow fluids to drain into it. The nurse shouldn't strip chest tubes because doing so may traumatize the tissue or dislodge the tube.
Which oxygen administration device has the advantage of providing a high oxygen concentration? Catheter Face tent Venturi mask Nonrebreathing mask
Nonrebreathing mask Explanation: Nonrebreathing masks provide high oxygen concentrations but usually fit poorly. A Venturi mask provides low levels of supplemental oxygen. A 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 a high oxygen concentration.
Which oxygen administration device has the advantage of providing a high oxygen concentration? Nonrebreathing mask Catheter Venturi mask Face tent
Nonrebreathing mask Explanation: The nonrebreathing mask provides high oxygen concentration, but it usually fits poorly. However, if the nonrebreathing mask fits the client snugly and both side exhalation ports have one-way valves, it is possible for the client to receive 100% oxygen, making the nonrebreathing mask a high-flow oxygen system. 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 a high oxygen concentration.
The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated? Routinely deflating the cuff Checking the cuff pressure every 6 to 8 hours Deflating the cuff before removing the tube Ensuring that humidified oxygen is always introduced through the tube
Routinely deflating the cuff Explanation: 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.
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 having a myocardial infarction. The patient is in a hypermetabolic state. The patient is hypoxic from suctioning. The patient is having a stress reaction.
The patient is hypoxic from suctioning. Explanation: 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? The system has an air leak. The chest tube is obstructed. The client has a pneumothorax. The system is functioning normally.
The system has an air leak. Explanation: 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.
Which type of ventilator has a preset volume of air to be delivered with each inspiration? Negative-pressure Time-cycled Pressure-cycled Volume-controlled
Volume-controlled Explanation: With volume-controlled ventilation, the volume of air to be delivered with each inspiration is preset. 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 preset pressure, and then cycles off, and expiration occurs passively.
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 Suction control chamber Collection chamber Air-leak chamber
Water-seal chamber Explanation: 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.
