Respiratory

The nurse is teaching the client in respiratory distress ways to prolong exhalation to improve respiratory status. The nurse tells the client to A. Sit in an upright position only. B. Initially inhale through the mouth. C. Purse the lips when exhaling air from the lungs. D. Hold the breath for 5 seconds and then exhale.

C. Purse the lips when exhaling air from the lungs. To prolong exhalation, the client may perform breathing while sitting in a chair or walking. The client is to inhale through the nose and then exhale against pursed lips. There is no holding the breath.

A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs? A. Inspection B. Chest X-ray C. Arterial blood gas (ABG) levels D. Auscultation

D. Auscultation 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.

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: A. 15 to 60 seconds. B. 5 to 20 minutes. C. 30 to 40 minutes. D. 45 to 60 minutes.

B. 5 to 20 minutes. Initially, the nurse should plug the opening in the tracheostomy tube for 5 to 20 minutes, then gradually lengthen this interval according to the client's respiratory status. A client who doesn't require continuous mechanical ventilation already is breathing without assistance, at least for short periods; therefore, plugging the opening of the tube for only 15 to 60 seconds wouldn't be long enough to reveal the client's true tolerance to the procedure. Plugging the opening for more than 20 minutes would increase the risk of acute respiratory distress because the client requires an adjustment period to start breathing normally.

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? A. Oxygen-induced hypoventilation B. Oxygen toxicity C. Oxygen-induced atelectasis D. Hypoxia

B. Oxygen toxicity Oxygen toxicity may occur when too high a concentration of oxygen (greater than 50%) is administered for an extended period (longer than 48 hours) (Urden, Stacy, & Lough, 2010). Signs and symptoms of oxygen toxicity include substernal discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxemia, alveolar atelectasis, and alveolar infiltrates evident on chest x-rays.

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.. "Slowly count to 7." 2. "Inhale through your nose." 3. "Exhale slowly through pursed lips." 4. "Slowly count to 3."

2. "Inhale through your nose." 4. "Slowly count to 3." 3. "Exhale slowly through pursed lips." 1. "Slowly count to 7." 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.

Constant bubbling in the water seal of a chest drainage system indicates which problem? A. Air leak B. Tidaling C. Tension pneumothorax D. Increased drainage

A. Air leak The nurse needs to observe for air leaks in the drainage system; they are indicated by constant bubbling in the water seal chamber, or by the air leak indicator in dry systems with a one-way valve. Tidaling is fluctuation of the water level in the water seal that shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent.

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? A. Auscultate the lung for adventitious sounds. B. Have the patient inform the nurse of the need to be suctioned. C. Assess the CO2 level to determine if the patient requires suctioning. D. Have the patient cough.

A. Auscultate the lung for adventitious sounds. 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.

For a client with an endotracheal (ET) tube, which nursing action is the most important? A. Auscultating the lungs for bilateral breath sounds B. Turning the client from side to side every 2 hours C. Monitoring serial blood gas values every 4 hours D. Providing frequent oral hygiene

A. Auscultating the lungs for bilateral breath sounds For the client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although turning the client from side to side every 2 hours, monitoring serial blood gas values every 4 hours, and providing frequent oral hygiene are appropriate actions for this client, they're secondary to ensuring adequate oxygenation.

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? A. Endotracheal suctioning B. Encouragement of coughing C. Use of a cooling blanket D. Incentive spirometry

A. Endotracheal suctioning Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.

The nurse should monitor a client receiving mechanical ventilation for which of the following complications? A. Gastrointestinal hemorrhage B. Immunosuppression C. Increased cardiac output D. Pulmonary emboli

A. Gastrointestinal hemorrhage 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 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. Kinking of the ventilator tubing B. A disconnected ventilator circuit C. An ET cuff leak D. A change in the oxygen concentration without resetting the oxygen level alarm

A. Kinking of the ventilator tubing 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.

Which oxygen administration device has the advantage of providing a high oxygen concentration? A. Nonrebreathing mask B. Venturi mask C. Catheter D. Face tent

A. Nonrebreathing mask 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 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? A. PaO2 B. pH C. PCO2 D. HCO3

A. PaO2 Hypoxemic hypoxia, or hypoxemia, is a decreased oxygen level in the blood (PaO2) resulting in decreased oxygen diffusion into the tissues.

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: A. Symmetry of the client's chest expansion B. Tracheal cuff pressure set at 30 mm Hg C. Cool air humidified through the tube D.A scheduled time for deflation of the tracheal cuff

A. Symmetry of the client's chest expansion Immediately after intubation, the nurse should check for symmetry of chest expansion. This is one finding that indicates successful endotracheal placement. The tracheal cuff pressure is set between 15 and 20 mm Hg. Routine deflation of the tracheal cuff is not recommended, because the client could then aspirate secretions during the period of deflation. Warm, high, humidified air is administered through the endotracheal 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? A. The patient is hypoxic from suctioning. B. The patient is having a stress reaction. C. The patient is having a myocardial infarction. D. The patient is in a hypermetabolic state.

A. The patient is hypoxic from suctioning. 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.

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? A. Water-seal chamber B. Air-leak chamber C. Collection chamber D. Suction control chamber

A. Water-seal chamber 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.

A client has a sucking stab wound to the chest. Which action should the nurse take first? A. Draw blood for a hematocrit and hemoglobin level. B.Apply a dressing over the wound and tape it on three sides. C. Prepare a chest tube insertion tray. D. Prepare to start an I.V. line.

B. Apply a dressing over the wound and tape it on three sides. The nurse should immediately apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line.

Which is a potential complication of a low pressure in the endotracheal tube cuff? A. Tracheal bleeding B. Aspiration pneumonia C. Tracheal ischemia D. Pressure necrosis

B. Aspiration pneumonia Low pressure in the cuff can increase the risk for aspiration pneumonia. High pressure in the cuff can cause tracheal bleeding, ischemia, and pressure necrosis

Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain? A. Fluid intake for the past 24 hours B. Baseline arterial blood gas (ABG) levels C. Prior outcomes of weaning D. Electrocardiogram (ECG) results

B. Baseline arterial blood gas (ABG) levels Before weaning the client from mechanical ventilation, it's most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins.

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? A. Anemic hypoxia B. Circulatory hypoxia C. Histotoxic hypoxia D. Hypoxic hypoxia

B. Circulatory hypoxia 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.

After suctioning a tracheostomy tube, the nurse assesses the client to determine the effectiveness of the suctioning. Which findings indicate that the airway is now patent? A. A respiratory rate of 28 breaths/minute with accessory muscle use B. Effective breathing at a rate of 16 breaths/minute through the established airway C. Increased pulse rate, rapid respirations, and cyanosis of the skin and nail beds D. Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds

B. Effective breathing at a rate of 16 breaths/minute through the established airway Proper suctioning should produce a patent airway, as demonstrated by effective breathing through the airway at a normal respiratory rate of 12 to 20 breaths/minute. The other options suggest ineffective suctioning. A respiratory rate of 28 breaths/minute and accessory muscle use may indicate mild respiratory distress. Increased pulse rate, rapid respirations, and cyanosis are signs of hypoxia. Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds indicate respiratory secretion accumulation.

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? A. Promote more efficient and controlled ventilation and to decrease the work of breathing B. Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing C. Promote the strengthening of the client's diaphragm D. Promote the client's ability to take in oxygen

B. Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing Pursed-lip breathing, which improves oxygen transport, helps induce a slow, deep breathing pattern and assists the client to control breathing, even during periods of stress. This type of breathing helps prevent airway collapse secondary to loss of lung elasticity in emphysema.

The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated? A. Deflating the cuff before removing the tube B. Routinely deflating the cuff C. Checking the cuff pressure every 6 to 8 hours D. Ensuring that humidified oxygen is always introduced through the tube

B. Routinely deflating the cuff 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.

A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? A. Check for an apical pulse. B. Suction the client's artificial airway. C. Increase the oxygen percentage. D. Ventilate the client with a handheld mechanical ventilator.

B. Suction the client's artificial airway. 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.

Which is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means? A. Nasal cannula B. Venturi mask C. T-piece D. Partial-rebreathing mask

B. Venturi mask The Venturi mask is the most reliable and accurate method for delivering a precise concentration of oxygen through noninvasive means. The mask is constructed in a way that allows a constant flow of room air blended with a fixed flow of oxygen. Nasal cannula, T-piece, and partial-rebreathing masks are not the most reliable and accurate methods of oxygen administration.

Which type of ventilator has a preset volume of air to be delivered with each inspiration? A. Negative pressure B. Volume cycled C. Time cycled D. Pressure cycled

B. Volume cycled With volume-cycled 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.

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? A. 45 mm Hg B. 58 mm Hg C. 84 mm Hg D. 120 mm Hg

C. 84 mm Hg 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 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 A. Consults with the physician about removing the client from the ventilator B. Changes the setting on the ventilator to increase breaths to 14 per minute C. Continues assessing the client's respiratory status frequently D. Contacts the respiratory therapy department to report the ventilator is malfunctioning

C. Continues assessing the client's respiratory status frequently 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 diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this patient? A. Surgery to remove the tonsils and adenoids B. Medications to assist the patient with sleep at night C. Continuous positive airway pressure D. Bi-level positive airway pressure

C. Continuous positive airway pressure Continuous positive airway pressure (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. To use CPAP, the patient must be breathing independently.

A client is postoperative and prescribed an incentive spirometer (IS). The nurse instructs the client to: A. Maintain a supine position to use the spirometer. B. Inhale and exhale rapidly with the spirometer. C. Expect coughing when using the spirometer properly. D. Use the spirometer twice every hour.

C. Expect coughing when using the spirometer properly. When using an incentive spirometer, the client should be sitting or in the semi-Fowler's position. The client is to inhale, hold the breath for about 3 seconds, and then exhale slowly. Coughing occurs with the use of the incentive spirometer and is encouraged. The client should use the spirometer 10 times every hour while awake.

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? A. Tracheostomy cleaning kit B. Water-seal chest drainage set-up C. Manual resuscitation bag D. Oxygen analyzer

C. Manual resuscitation bag 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.

A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? A. The system is functioning normally. B. The client has a pneumothorax. C. The system has an air leak. D. The chest tube is obstructed.

C. The system has an air leak. 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.

After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must: A. report fluctuations in the water-seal chamber. B. clamp the chest tube once every shift. C. encourage coughing and deep breathing. D. milk the chest tube every 2 hours.

C. encourage coughing and deep breathing. When caring for a client who's recovering from a thoracotomy, the nurse should encourage coughing and deep breathing to prevent pneumonia. Fluctuations in the water-seal chamber are normal. Clamping the chest tube could cause a tension pneumothorax. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage.

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? A. Have the patient lie in a supine position during the use of the spirometer. B. Encourage the patient to try to stop coughing during and after using the spirometer. C. Inform the patient that using the spirometer is not necessary if the patient is experiencing pain. D. Encourage the patient to take approximately 10 breaths per hour, while awake

D. Encourage the patient to take approximately 10 breaths per hour, while awake. 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.