N 403 Ch 21 PrepU
Postural drainage for upper lobes
Upper Lobes, apical segments
postural drainage for superior lower lobes
Lower Lobes, superior segments
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? - 10 minutes - 15 minutes - 20 minutes - 25 minutes
Correct response: 20 minutes Explanation: The nurse records minute volume and obtains ABGs to measure carbon dioxide partial pressure (PaCO2), pH, and PaO2 after 20 minutes of continuous mechanical ventilation.
Postural drainage for Lower lobes
Upper lobes, anterior segments
Postural drainage for Upper lobes
Upper lobes, posterior segments
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. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. - "Slowly count to 7." - "Slowly count to 3." - "Exhale slowly through pursed lips." - "Inhale through your nose."
Correct response: "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.
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." - "Exhale forcefully while the chest tube is being removed." - "While the chest tube is being removed, raise your arms above your head." - "Do not move during the removal of the chest tube because moving will make it more painful."
Correct response: "When the tube is being removed, take a deep breath, exhale, and bear down." Explanation: When assisting in removal of a chest tube, instruct the client 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 client.
A client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. The client is placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. What setting would be the best maximum FIO2 setting? - 0.21 - 0.35 - 0.5 - 0.7
Correct response: 0.5 Explanation: An FIO2 greater than 0.5 for as little as 16 to 24 hours can be toxic and can lead to decreased gas diffusion and surfactant activity. Clients with respiratory disorders are given oxygen therapy only to increase the partial pressure of oxygen (PaO2) back to the patient's normal baseline, which may vary from 60 to 95 mm Hg. In terms of the oxyhemoglobin dissociation curve, arterial hemoglobin at these levels is 80% to 98% saturated with oxygen; higher FiO2 flow values add no further significant amounts of oxygen to the red blood cells or plasma. Instead of helping, increased amounts of oxygen may produce toxic effects on the lungs and central nervous system or may depress ventilation. The ideal oxygen source is room air FIO2 0.21.
A client 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 sleeve resection - A lung volume reduction - A wedge resection - Lobectomy
Correct response: A lung volume reduction Explanation: Lung volume reduction is a surgical procedure involving the removal of 20%-30% of a client's lung through a midsternal incision or video thoracoscopy. The diseased lung tissue is identified on a lung perfusion scan. This surgery leads to significant improvements in dyspnea, exercise capacity, quality of life, and survival of a subgroup of people with end-stage emphysema.
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 - Sets a schedule to suction the tracheostomy every hour - Assesses the client's tracheostomy and lung sounds every 15 minutes - Decreases the amount of humidity set to flow through the tracheostomy tube - Encourages the client to cough every 30 minutes and prn
Correct response: Assesses the client's tracheostomy and lung sounds every 15 minutes Explanation: Tracheal suctioning is performed when secretions are obvious or adventitious breath sounds are heard. The client is producing thick yellow mucus frequently, so the nurse needs to make frequent assessments about the need for suctioning. Suctioning every hour could be too frequent or not frequent enough. It also does not address the client's needs. The client needs high humidity to liquify the mucus, which is described as thick. The client has a decreased effectiveness of coughing with a tracheostomy tube. Again, this is not a viable option.
Which ventilator mode provides full ventilatory support by delivering a preset tidal volume and respiratory rate? - IMV - SIMV - Assist control - Pressure support
Correct response: Assist control Explanation: 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 client 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 client-triggered inspiration to decrease resistance within the tracheal tube and ventilator tubing.
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. - Have the patient inform the nurse of the need to be suctioned. - Assess the CO2 level to determine if the patient requires suctioning. - Have the patient cough.
Correct response: 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.
What assessment method would the nurse use to determine the areas of the lungs that need draining? - Inspection - Chest X-ray - Arterial blood gas (ABG) levels - Auscultation
Correct response: 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.
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 - PaO2 60 mmHg with an FiO2 - Heart rate - Vital capacity of 12 mL/kg
Correct response: Blood pressure increase of 20 mm Hg Explanation: Criteria for terminating the weaning process include: a heart rate increase of 20 beats/min, systolic blood pressure increase of 20 mm Hg, a decrease in oxygen saturation to less than 90%, respiratory rate less than 8 or greater than 20 breaths/min, ventricular dysrhythmias, fatigue, panic, cyanosis, erratic or labored breathing, and paradoxical chest movement. criteria that indicate a client is ready to be weaned from the ventilator: A vital capacity of 10 to 15 mL/kg, maximum inspiratory pressure (MIP) at least -20 cm H2O, tidal volume of 7 to -9 mL/kg, minute ventilation of 6 L/min, and a rapid/shallow breathing index below 100 breaths/min/L; PaO2 greater than 60 mm Hg with FiO2 less than 40% . A normal vital capacity is 10 to 15 mL/kg.
The nurse is caring for a client in the ICU who is receiving mechanical ventilation. Which nursing measure is implemented in an effort to reduce the client's risk of developing ventilator-associated pneumonia (VAP)? - Cleaning the client's mouth with chlorhexidine daily - Maintaining the client in a high Fowler's position - Ensuring that the client remains sedated while intubated - Turning and repositioning the client every 4 hours
Correct response: Cleaning the client's mouth with chlorhexidine daily Explanation: The five key elements of the VAP bundle include elevation of the head of the bed (30 to 45 degrees [semi-Fowler's position)], daily "sedation vacations," and assessment of readiness to extubate; peptic ulcer disease prophylaxis (with histamine-2 receptor antagonists); deep venous thrombosis prophylaxis; and daily oral care with chlorhexidine (0.12% oral rinses). The client should be turned and repositioned every 2 hours to prevent complications of immobility and atelectasis and to optimize lung expansion.
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 Consults with the physician about removing the client from the ventilator Changes the setting on the ventilator to increase breaths to 14 per minute Continues assessing the client's respiratory status frequently Contacts the respiratory therapy department to report the ventilator is malfunctioning
Correct response: 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 client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the mosteffective for this client? Surgery to remove the tonsils and adenoids Medications to assist the patient with sleep at night Continuous positive airway pressure (CPAP) Bi-level positive airway pressure (BiPAP)
Correct response: Continuous positive airway pressure (CPAP) Explanation: CPAP provides positive pressure to the airways throughout the respiratory cycle. Although it can be used as an adjunct to mechanical ventilation with a cuffed endotracheal tube or tracheostomy tube to open the alveoli, it is also used with a leak-proof mask to keep alveoli open, thereby preventing respiratory failure. CPAP is the most effective treatment for obstructive sleep apnea because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. CPAP is used for clients who can breathe independently. BiPAP is most often used for clients who require ventilatory assistance at night, such as those with severe COPD or sleep apnea.
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. - Restrict intravenous fluids for at least 24 hours. - Make sure that a thoracotomy tube is linked to open chest drainage. - Assist with positioning the client on the right side.
Correct response: Encourage coughing to mobilize secretions. Explanation: The client is encouraged to cough frequently to mobilize secretions. The client will be placed in the semi-Fowler's position. The chest tube is 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.
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. - 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.
Correct response: 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 should monitor a client receiving mechanical ventilation for which of the following complications? - Gastrointestinal hemorrhage - Immunosuppression - Increased cardiac output - Pulmonary emboli
Correct response: Gastrointestinal hemorrhage Explanation: Gastrointestinal hemorrhage occurs in approximately 25% of clients receiving prolonged mechanical ventilation. Other possible complications include incorrect ventilation, oxygen toxicity, fluid imbalance, decreased cardiac output, pneumothorax, infection, and atelectasis. Immunosuppression and pulmonary emboli are not direct consequences of mechanical ventilation.
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? - Tracheostomy cleaning kit - Water-seal chest drainage set-up - Manual resuscitation bag - Oxygen analyzer
Correct response: Manual resuscitation bag Explanation: The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit at the bedside isn't necessary. Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate the effectiveness of ventilation, this equipment is less important than the manual resuscitation bag.
Positive end-expiratory pressure (PEEP) therapy has which effect on the heart? - Bradycardia - Tachycardia - Increased blood pressure - Reduced cardiac output
Correct response: Reduced cardiac output Explanation: PEEP reduces cardiac output by increasing intrathoracic pressure and reducing the amount of blood delivered to the left side of the heart. It doesn't affect heart rate, but a decrease in cardiac output may reduce blood pressure, commonly causing compensatory tachycardia, not bradycardia. However, the resulting tachycardia isn't a direct effect of PEEP therapy itself.
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? Check for an apical pulse. Suction the client's artificial airway. Increase the oxygen percentage. Ventilate the client with a handheld mechanical ventilator.
Correct response: Suction the client's artificial airway. Explanation: A high-pressure alarm on a continuous mechanical ventilator indicates an obstruction in the flow of gas from the machine to the client. The nurse should suction the client's artificial airway to remove respiratory secretions that could be causing the obstruction. The sounding of a ventilator alarm has no relationship to the apical pulse. Increasing the oxygen percentage and ventilating with a handheld mechanical ventilator wouldn't correct the airflow blockage.
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? - Call the physician. - Remove the malfunctioning cuff. - Add more air to the cuff. - Suction the client, withdraw residual air from the cuff, and reinflate it.
Correct response: Suction the client, withdraw residual air from the cuff, and reinflate it. Explanation: After discovering an air leak, the nurse first should check for insufficient air in the cuff — the most common cause of a cuff air leak. To do this, the nurse should suction the client, withdraw all residual air from the cuff, and then reinflate the cuff to prevent overinflation and possible cuff rupture. The nurse should notify the physician only after determining that the air leak can't be corrected by nursing interventions, or if the client develops acute respiratory distress. The tracheostomy tube cuff can't be removed and replaced with a new one without changing the tracheostomy tube; also, removing the cuff would create a total air leak, which isn't correctable. Adding more air to the cuff without first removing residual air may cause cuff rupture.
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. - The patient is having a stress reaction. - The patient is having a myocardial infarction. - The patient is in a hypermetabolic state.
Correct response: 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 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 be extubated and another endotracheal tube will be inserted. - The patient will be extubated and a nasotracheal tube will be inserted. - The patient will have an insertion of a tracheostomy tube. - The patient will begin the weaning process.
Correct response: The patient will have an insertion of a tracheostomy tube. Explanation: Endotracheal intubation may be used for no longer than 14 to 21 days, by which time a tracheostomy must be considered to decrease irritation of and trauma to the tracheal lining, to reduce the incidence of vocal cord paralysis (secondary to laryngeal nerve damage), and to decrease the work of breathing (Wiegand, 2011).
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 - To clear respiratory secretions - To provide visual feedback to encourage the client to inhale slowly and deeply
Correct response: To provide adequate transport of oxygen in the blood To decrease the work of breathing To reduce stress on the myocardium Explanation: Oxygen therapy is designed to provide adequate transport of oxygen in the blood while decreasing the work of breathing and reducing stress on the myocardium. Incentive spirometry is a respiratory modality that provides visual feedback to encourage the client to inhale slowly and deeply to maximize lung inflation and prevent or reduce atelectasis. A mini-nebulizer is used to help clear secretions.
A client is being mechanically ventilated with an oral endotracheal tube in place. The nurse observes that the cuff pressure is 28 mm Hg. The nurse is aware of what complications that can be caused by this pressure? Select all that apply. - Tracheal aspiration - Hypoxia - Tracheal ischemia - Tracheal bleeding - Pressure necrosis
Correct response: Tracheal ischemia Tracheal bleeding Pressure necrosis Explanation: Complications can occur from pressure exerted by the cuff on the tracheal wall. Cuff pressures should be maintained between 20 and 25 mm Hg. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis, whereas low cuff pressure can increase the risk of aspiration pneumonia. Routine deflation of the cuff is not recommended because of the increased risk of aspiration and hypoxia.
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 - Air-leak chamber - Collection chamber - Suction control chamber
Correct response: 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.
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 malignant tumor. - pneumonia. - hyperthermia.
Correct response: a compromised skin graft. Explanation: 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 client who is scheduled for a lobectomy. Following the procedure, the nurse will plan care based on the client - returning to the nursing unit with two chest tubes. - returning from surgery with no drainage tubes. - requiring mechanical ventilation following surgery. - requiring sedation until the chest tube(s) are removed.
Correct response: returning to the nursing unit with two chest tubes. Explanation: The nurse should plan for the client 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.
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.
Suction control is determined by the height of instilled water in that chamber. The suction control chamber is on the left side. In the middle of the closed drainage system is the water-seal chamber. The drainage chamber is on the right side of the closed drainage system.
