Chapter 21: Respiratory Care Modalities
The nurse is preparing to assist the health care provider to remove a client's chest tube. Which instruction will the nurse correctly give to the client?
"When the tube is being removed, take a deep breath, exhale, and bear down."
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 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
When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for how long?
10 to 15 seconds
Which range of water pressure within the endotracheal tube cuff is believed to prevent both injury and aspiration?
15 to 20 mm Hg
The nurse is caring for a client in the ICU who required emergent endotracheal (ET) intubation with mechanical ventilation. The nurse receives an order to obtain arterial blood gases (ABGs) after the procedure. The nurse recognizes that ABGs should be obtained how long after mechanical ventilation is initiated?
20 minutes
The nurse is assigned to care for a client with a chest tube. The nurse should ensure that which item is kept at the client's bedside?
A bottle of sterile water
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 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
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
For a client with an endotracheal (ET) tube, which nursing action is the most important?
Auscultating the lungs for bilateral breath sounds
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
Which is an adverse reaction that would require the process of weaning from a ventilator to be terminated?
Blood pressure increase of 20 mm Hg
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
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 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 has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result?
Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing
Which finding would indicate a decrease in pressure with mechanical ventilation?
Increase in compliance
The nurse is educating a patient with COPD about the technique for performing pursed-lip breathing. What does the nurse inform the patient is the importance of using this technique?
It prolongs exhalation.
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
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
Which oxygen administration device has the advantage of providing a high oxygen concentration?
Nonrebreathing mask
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
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
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)
A nurse is caring for a client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do?
Place the end of the chest tube in a container of sterile saline.
The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated?
Routinely deflating the cuff
A nurse is weaning a client from mechanical ventilation. Which assessment finding indicates the weaning process should be stopped?
Runs of ventricular tachycardia
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.
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 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 is being mechanically ventilated in the ICU. The ventilator alarms begin to sound. The nurse should complete which action FIRST?
Troubleshoot to identify the malfunction.
Which is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means?
Venturi mask
Which type of ventilator has a preset volume of air to be delivered with each inspiration?
Volume-controlled
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).
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.
Which ventilator mode provides full ventilatory support by delivering a preset tidal volume and respiratory rate?
Assist control
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 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.
The nurse is caring for a client following a thoracotomy. Which finding requires immediate intervention by the nurse?
Chest tube drainage, 190 mL/hr
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 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 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 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
1. Sit in an upright position. 2. Place the mouthpiece of the spirometer in the mouth. 3. Breathe air in through the mouth. 4. Hold breath for about 3 seconds. 5. Exhale air slowly through the mouth.
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
The nurse is caring for a client following a wedge resection. While the nurse is assessing the client's chest tube drainage system, constant bubbling is noted in the water seal chamber. This finding indicates which problem?
Air leak
Which is a potential complication of a low pressure in the endotracheal tube cuff?
Aspiration pneumonia
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 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.
The nurse is caring for a client being weaned from a mechanical ventilator. Which findings would require the weaning process to be terminated?
Blood pressure increase of 20 mm Hg from baseline
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
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 hears the patient's ventilator alarm sound and attempts to find the cause. What is the priority action of the nurse when the cause of the alarm is not able to be determined?
Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved.
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 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.
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
