Oxygenation
Which statement accurately describes a closed suction system?
A system that is attached to a tracheostomy or endotracheal tube and is reused frequently
The nurse is performing tracheostomy care on a client and notices that behind the neck plate there is some redness and skin breakdown. Which action will reduce further complications?
Add a drain sponge (split 4x4) between the stoma and neck plate
Once the suction catheter is connected to suction, which action should the nurse perform next?
Advance the catheter down the tube before applying suction.
What are some indications that suctioning is necessary? Select all that apply.
Decreased oxygen saturation Frequent coughing Increased respiratory rate
Which muscle group is primarily responsible for the inflation of the lungs?
Diaphragm
The chest x-ray results confirm community-acquired pneumonia. Both the electrocardiogram and echocardiogram are normal. Based on these results, what is the most likely cause of the client's increased respirations?
Hypoxemia
Hypoxia vs Hypoxemia
Hypoxia: 1. Not enough functional red blood cells 2. Blood is not reaching the tissues 3. Cyanide poisoning Hypoxemia: 1.Hypoventilation 2. Oxygen is not reaching the alveoli 3. Diffusion impairment
Which statement is accurate when communicating with a client with a tracheostomy tube?
Use a pencil and paper to allow the client to write responses.
The nurse is performing routine tracheostomy care on a client. There is a supply shortage of drain sponges (split 4x4). What can be used in place of the drain sponge?
Use a regular 4x4 folded on either side of the stoma.
Based on the assessment findings, the client's impaired gas exchange is most likely a result of which system?
cardiac
Which diagnostic test should the nurse anticipate being ordered?
chest x ray
Impaired gas exchange
compensate homeostasis damage
How often should routine tracheostomy care be completed?
every shift
What is the color of an oxygen cylinder designated as the standard in the United States?
green
The client is admitted with dyspnea. They are tachypneic at 30 with a blood pressure of 160/90, pulse of 125 and regular, and oxygen saturation is 88%. What is the priority nursing diagnosis for this client?
impaired gas exchange
What is the priority nursing diagnosis for this client?
impaired gas exchange
Which priority order from the healthcare provider should the nurse anticipate receiving?
oxygen
When using supplemental oxygen, what equipment determines the amount of oxygen the client receives?
regulator
Match the oxygen percentage delivered with the type of oxygen delivery in the table.
room air: 21 nasal: 24-40 simple: 35-50 venturi: 24-50 partial: 60-80 full: 100
Where should the regulator be set? For each label, select "Yes" to indicate the correct rate of flow or "No" to indicate the incorrect flow rate.
spot number 3 is the only yes the rest are no
After the suction device is set, which nursing action should the nurse perform next?
sterile gloves
Available at Bedside for Emergency Use
suction tubing and oral suctioning tool Tracheostomy tube in package Working suction unit
Interventions to improve gas exchange
ventilation device: 1. cannot take deep breath 2. stopped breathing oxygen: 1. oxygen saturation 78% inhaled med: 1. asthmatic wheezing
What is the purpose of a pilot balloon?
It signals if the cuff is inflated or deflated.
Identify the parts of a tracheostomy tube.
1: trach tube 2: cuff 3: pilot balloon 4: inner cannula 5: obturator
The nurse is assessing Gus an hour after the ventilator was replaced with oxygen via a trach collar. The lungs have scattered rhonchi and Gus is coughing frequently. For each clue pictured, select the best action the nurse should take.
1: turn up 2: assess for airway patency 3: no recommendations
What equipment should be placed in Gus' room before he returns from surgery? Select all that apply.
#8 tracheostomy tube cuffed with disposable inner cannula Tracheostomy dressing kit #8 disposable inner cannula Suction kit (sterile) Bag-valve-mask - adult
What percentage of the air we breathe is oxygen?
21
Place the suctioning steps in the correct order, from first to last.
1. Explain 2. increase 3. set suction 4. remove oxygen 5. insert suction 6. apply intermittent 7. reapply oxygen 8. wait 30-60 seconds
Pulmonary diagnostic tests
1. Oximeter, hypoxemia 2. Chest x-ray, ventilation 3. lab testing, hypoxemia 4. spirometry, ventilation
The nurse enters an adult client's room and notices they have stopped breathing. Which three priority actions should the nurse take first?
1. Ventilate the client with a bag-valve-mask device. 2. Gently shake the client and call their name. 3. call for help
Drag the names of the catheter parts to their correct locations.
1. catheter 2. catheter tip 3. suction valve
Cardiac diagnostic testing
1. lab testing, MI 2. Electrocardiogram, dysrhythmia 3. Echocardiogram, dysfunctional valve 4. cardiac catheterization, decreased blood flow
What is the maximum amount of time that suction can be applied while suctioning a tracheostomy?
10 seconds
To what value should the nurse adjust the suction regulator?
100 mmHg
What size suction catheter would be appropriate?
12 French suction catheter
A client using oxygen at 2 L/min via nasal cannula to keep their oxygen saturation greater than 92% needs to be transported to the x-ray department. The nurse is assessing the client and the oxygen equipment. Based on the images provided, select the statement that best describes the assessment findings.
1: oxygen saturation is adequate 2: this flow rate should be decreased by 1 L/min 3: there is enough oxygen to transport the client 4: client has the correct oxygen delivery device on
As the nurse advances the suction catheter to the carina, the client begins to cough. What action should the nurse take?
Apply intermittent suction as the catheter is withdrawn from the tube.
When changing the tracheostomy ties and no assistance is available, which is the proper sequence to follow?
Apply the new ties while the old ties are still intact, ensuring a double knot is used to secure the ties to the neck plate with the twill traveling around the back of the neck, then remove the old ties.
A client with no spontaneous respirations is being supported on a ventilator with 40% oxygen being delivered. When the ventilator stops working, which device should the nurse select to support the client until a replacement ventilator arrives?
Bag-valve-mask delivering 50% oxygen
The nurse comes across an oxygen tank that is not in use but is making a loud "hissing" sound. What is the best course of action?
Turn the valve on the top of the tank clockwise (to the right) until it cannot be turned anymore.
During a shift assessment, the nurse notices that a client receiving 4 L of oxygen by nasal cannula has bloody tissues in their hand. The client reports that their nose is sore and has been bleeding for the last 20 minutes. What should the nurse do next?
Contact the healthcare provider.
Needed for Tracheostomy Care
Cotton-tipped applicators Basin Saline Gauze 4x4 Cleaning brush Twill tape Sterile gloves Split 4x4 Scissors
Based on the assessment findings, which diagnostic tests should the nurse anticipate will be ordered? Select all that apply.
Echocardiogram Blood work Cardiac catheterization Electrocardiogram
During report, the nurse learns that a client is wearing a mask that delivers 90% oxygen with a flow rate of 15 L/min. Which type of oxygen mask should the nurse anticipate the client is using?
Full non-rebreather mask
What are the advantages to using a closed suction system? Select all that apply.
Ideal for frequent suctioning in someone with heavy secretions Maintains sterile environment continuously Automatically delivers oxygen throughout the suction process
One hour after providing tracheostomy (trach) care, the nurse returns to assess Gus, who is resting comfortably. Gus is not coughing, his lungs are clear to auscultation, and his oxygen saturation (O2 sat) is 96% on 10 L/min of humidified oxygen via a trach collar. Which priority action should the nurse take at this time?
Inform Gus that they will return in an hour.
Which procedure is the proper way to perform open tracheal suctioning?
Insert the tube without suctioning, then begin intermittent suctioning with the catheter completely inserted and continue while withdrawing the catheter.
Which pathophysiological condition is causing this impaired gas exchange?
MI
What is the main difference between continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP)?
One machine offers a static pressure for inspiration and expiration, while the other offers a different pressure for each.
Which statement about oxygen is accurate?
Oxygen is a medication requiring an order to administer.
Use the drop-down menus to select the information each of the gauges is indicating.
Oxygen is set at 3 L/min Oxygen tank is almost empty
While assessing a client with the healthcare provider's order to receive 100% oxygen via a non-rebreather mask, the nurse notes the equipment as shown in the image. What should the nurse do next?
Replace the mask with a full non-rebreather mask.
Which supplies are required when performing tracheostomy care? Select all that apply.
Saline Gauze 4x4 Cleaning brush Scissors Sterile gloves Twill tape Cotton-tipped applicators Split 4x4 Basin
Which information does a pulse oximeter measure?
Saturation of hemoglobin with oxygen
Which technique is followed when performing open tracheal suctioning in an acute care facility?
Sterile technique with a sterile catheter
What should the nurse do first?
Suction the client with a sterile suction catheter.
The nurse is preparing to perform tracheostomy care on a client who is receiving 50% oxygen via a trach collar and coughing. The nurse notes that the client's oxygen saturation levels have decreased over the last hour. What is the priority action the nurse should take first?
Suction through the tracheostomy tube.
what are some reasons for tracheostomy placement? Select all that apply.
Trauma-causing upper airway obstruction Laryngectomy Long-term ventilator use
What is the priority concern for the nurse working with a client who breathes through a tracheotomy?
The tube could accidentally fall out.
After Gus arrives at the step-down unit, the nurse observes Gus' tracheostomy, which is a #8 cuffed tracheostomy tube with a disposable inner cannula. Observe the image below and then select the information that accurately describes how Gus' tracheostomy site looks now.
Trach ties appear intact Ventilator tube appears to be connected Dressing dry and intact Trach care will need to be done this shift
After the first suctioning pass, the nurse hears gurgling from the tracheostomy tube. What should the nurse do next?
Wait at least 30 to 60 seconds before performing another suction attempt
Gus' spouse asks why he needs a tracheostomy. What is the best response by the nurse?
this will reduce some of his discomfort and helps support his airway.
