210 - Exam 3 Comfort, Pain, and Oxygenation

After teaching a patient scheduled for ambulatory surgery using moderate sedation, the nurse determines that the patient has understood the teaching based on which of the following statements?

"I'll be sleepy but able to respond to your questions." With moderate sedation, the patient can maintain a patent airway (i.e., doesn't need a tube to help breathing), retain protective airway reflexes, and respond to verbal and physical stimuli. The patient is not unconscious with moderate sedation. Local anesthesia involves anesthetizing or numbing the area of the surgery.

The nurse is caring for a client utilizing a Patient Controlled Analgesia (PCA) pump that is programmed to allow a bolus dose every 10 minutes. The client is sleeping with visitors at the bedside. Which of the following instructions should the nurse give the client's visitors?

"Only the client should push the pump button." The nurse should instruct the visitors that only the client should push the button on the pump to administer the bolus pain medication. Unauthorized family members or caregivers (instead of the client) who administer PCA by pushing the dosage button can cause serious analgesic overdoses resulting in oversedation, respiratory depression, and death. The client should push the pump's button only when feeling the sensation of pain.

A female client is 12 hours post-appendectomy. Her son asks the nurse to reduce the amount of pain medication that his mother is taking. He states, "When I had my appendix out, I needed half the pain medication that she does." What is the nurse's best response?

"Pain is a subjective experience; we all feel pain differently." Pain is a subjective experience. Stressors such as anxiety, depression, fatigue, anger, and fear tend to increase pain; rest, mood elevation, and diversionary activities tend to decrease pain. Pain is a complex physiologic, psychological, and sociocultural phenomenon that must be thoroughly assessed to be managed effectively.

How often should I replace the water in an oxygen nebulizer?

Typically, you'd replace the water in the oxygen nebulizer, which is used to deliver humidification to the patient, when the level is low or at least every 24 hours. However, be sure to follow your facility's policies and procedures for replacing the water.

How often should I replace the disposable closed-chest drainage system my patient has?

Unless the system has been compromised in some way, there is no need to replace it until the collection chamber is nearly full.

A nurse is evaluating the effectiveness of the preoperative education regarding pain control and the use of patient-controlled analgesia (PCA). Which statement by the client would indicate a need for further education?

"I will have my wife push the PCA button once while I nap so I don't have pain on awakening." The client should be the only one to administer medication via the PCA pump. Using the pump prior to getting out of bed and/or ambulating will help decrease the pain. Distraction is an effective nonpharmacologic means of dealing with pain. Constipation is a common side effect from many pain medications. Increasing fluid intake is one way of attempting to prevent it.

A female client is crying and states that everyone thinks she is a "drug addict," and that no one will listen to her. She states she has abdominal pain and must have something for the pain. What is the best response of the nurse?

"Tell me more about your pain." Nurses must lessen the barriers to good pain management by showing sensitivity to the client and conducting a through assessment. The nurse needs to encourage the client to share information regarding pain so that an appropriate treatment plan can be designed. To do this open ended statements need to be made. Questions with yes/no responses are not as therapeutic. Nurses must demonstrate nonjudgmental attitudes with clients.

A client is in the hospital recovering from surgery. The client's adult child tells the nurse that they are concerned their parent will overdose on morphine because they keep pressing the button on the patient-controlled anesthesia (PCA) pump. In addition to reassessing the client's pain, what is the nurse's best response?

"The device has maximum limits programmed, so your parent cannot get more than a specific amount." A PCA system using morphine provides a baseline, constant infusion of morphine and gives the client control of the system to add bolus doses of morphine if the client believes that pain is not being controlled. The system prevents overdose by locking out extra doses until a specific period of time has elapsed. Offering to teach relaxation techniques to the family member does not address the expressed concern.

The nurse is caring for a 9-year-old one-day post-op appendectomy client. She is due to receive a dose of IV morphine. Her mother is at the bedside and asks why her daughter needs another dose of morphine when she received one just 4 hours ago. Which statement shows the nurse's understanding of pain management?

"The physician has ordered morphine to be given around the clock in order to keep on top of your daughter's postoperative pain."

The nurse is caring for a 9-year-old one-day post-op appendectomy client. She is due to receive a dose of IV morphine. Her mother is at the bedside and asks why her daughter needs another dose of morphine when she received one just 4 hours ago. Which statement shows the nurse's understanding of pain management?

"The physician has ordered morphine to be given around the clock in order to keep on top of your daughter's postoperative pain." It is important to provide pain medication around the clock to manage pain more effectively and avoid peaks and cycles of pain. The response "I am just following the doctor's orders" does not answer the question. The mother never expressed concern about her daughter becoming an addict. Asking if the mother wants her daughter to be in pain is judgmental and inappropriate.

The nurse administers an oral opioid analgesic to a client at 6 PM for pain documented as 6 on a scale of 0 to 10. At 6:30 PM, the client states that the pain level is 3 on a scale of 0 to 10, and that level is acceptable to him. The client asks the nurse why another assessment was necessary after the administration of the pain medication. What is the nurse's best response to this client about proper pain management?

"We assess every client in relation to pain, initially to determine appropriate interventions and later to determine whether the interventions were effective in preventing or relieving pain." The nurse must assess every client in relation to pain, initially to determine appropriate interventions and later to determine whether the interventions were effective in preventing or relieving pain.

A nurse is educating a client about regional anesthesia. Which statement is accurate about this type of anesthesia?

"You will be awake and will not have sensation of the procedure." Regional anesthesia occurs when an anesthetic agent is injected near a nerve or nerve pathway in or around the operative site, inhibiting the transmission of sensory stimuli to central nervous system receptors. The client remains awake but loses sensation in a specific area or region of the body. Monitored anesthesia care is when the client is asleep but may feel some pain during the procedure. Conscious sedation is when the client is awake but will not be aware of the procedure. General anesthesia is when the client is asleep and will not be aware of the procedure.

The pediatric nurse is caring for four clients. Which client will receive the greatest benefit from the use of an oxygen analyzer to assure that the client is receiving the prescribed amount of oxygen?

3-year old in croup tent Explanation: An oxygen analyzer is used most commonly when caring for newborns in isolettes, children in croup tents, and clients who are mechanically ventilated.

The nurse is caring for a patient with COPD. The patient is receiving oxygen therapy via nasal cannula. The nurse understands that the goal of oxygen therapy is to maintain the patient's SaO2 level at or above what percent?

90% Explanation: The goal of supplemental oxygen therapy is to increase the baseline resting partial arterial pressure of oxygen (PaO2) to at least 60 mm Hg at sea level and arterial oxygen saturation (SaO2) to at least 90%.

A nurse is caring for a client who has a tracheostomy. Which of the following pieces of equipment should the nurse use when administering oxygen to this client?

A tracheostomy collar: A tracheostomy collar is a piece of equipment that fits over the tracheostomy site and is held in place by an adjustable elastic strap that fits around the client's neck. The collar provides the client with the prescribed oxygen concentration while also providing high humidity.

The nurse is caring for a patient following a wedge resection. While the nurse is assessing the patient's chest tube drainage system, constant bubbling is noted in the water seal chamber. This finding indicates which of the following problems?

Air leak Tension pneumothorax Increased drainage Tidaling 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.

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 Explanation: 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 nurse is preparing to suction a client's tracheostomy. Which of the following actions should the nurse take?

Allow 2 min in between suctioning to reoxygenate the lungs: The nurse should allow 2 to 3 min in between each pass to allow the client to cough and deep breathe and allow the lungs to reoxygenate. incorrect rationale: Suction for 30 seconds with each pass: The nurse should suction 10 to 20 seconds with each pass to minimize oxygen loss and allow the client to cough and deep breathe in between. Use a rotating motion when inserting the catheter from the tracheostomy: The nurse should use a rotating motion when withdrawing the catheter while suctioning to minimize tissue trauma and reduce suction time against the client's trachea Set the suction pressure to 180 mm Hg: The nurse should set the suction up to 120 mm Hg for open suctioning and up to 160 mm Hg for closed system suctioning.

The nurse has prepared hydromorphone 1 mg I.V. for a client reporting pain 7/10. Just prior to administration, the client requests an oral pain medication instead. What is the priority action by the nurse?

Ask another nurse to witness the waste of the prepared medication. Hydromorphone is a Schedule II controlled substance and federal law requires accurate records of administration to prevent diversion and misuse of the substance. If a controlled substance is not immediately administered after removing from the locked cabinet, it should be wasted in the sink or approved pharmaceutical waste container with witness and documentation by two nurses. Controlled substances should never be wasted in a sharps container or stored in an unlocked medication drawer as this provides access to the medication for potential misuse. The client's wishes for oral pain management should be honored. The prepared dose should be wasted per facility protocol and the oral medication be administered.

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. Explanation: If the client uses an alternative method of communication, such as writing, using a picture board, or spelling words on an alphabet board, he'll feel more in control and be less frustrated. Assuring the client that everything will be all right offers false reassurance and telling him not to be upset minimizes his feelings. Neither of these methods helps the client to communicate. Family members are also likely to encounter difficulty interpreting the wishes of a client with an endotracheal tube or tracheostomy tube. Making them responsible for interpreting the client's gestures may frustrate them. The client may be weaned off a mechanical ventilator only when the physiologic parameters for weaning have been met.

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 Explanation: A nonrebreather mask can deliver high concentrations of oxygen to the client in acute respiratory distress. Assessment of a client's status is a priority for determining the effectiveness of therapy. There is no need for the nurse to post a "No smoking" sign over the client's bed. Smoking is a fire hazard and is prohibited in hospitals regardless of whether the client is receiving oxygen from a nonrebreather mask. Oil-based lubricants can cause pneumonia by promoting bacteria growth. Equipment should be changed daily, but this is a lower priority than assessing respiratory status, orientation, and skin color.

When the nurse is performing an assessment and finds no physical cause for a patient's pain, what should the nurse do when the patient continues to complain of pain?

Believe a patient when he or she states that pain is present. The highly subjective nature of pain causes challenges in assessment and management; however, the patient's self-report is the undisputed standard for assessing the existence and intensity of pain (APS, 2008; McCaffery et al., 2011). Accepting and acting on the patient's report of pain are sometimes difficult. Because pain cannot be proved, the health care team is vulnerable to inaccurate or untruthful reports of pain. Clinicians are entitled to their personal doubts and opinions, but those doubts and opinions cannot be allowed to interfere with appropriate patient care.

List education to provide to a patient who is going home with a new order for oxygen

Check oxygen setting daily Check for skin breakdown on ears and nose Post no smoking signs around and outside of the house Ordering and maintenance of supplies and equipment Signs & symptoms to monitor for Etc.

Which would the nurse most likely expect as treatment for a pneumothorax?

Chest tube insertion Explanation: Chest tube insertion would be important for a pneumothorax to restore the negative pressure. Anti-infective therapy would be appropriate for an infection. Control of allergen exposure would be appropriate for asthma. Surfactant replacement would be appropriate for respiratory distress syndrome.

The health care provider has ordered a patient controlled analgesia (PCA) pump for a client. Which assessment finding would cause the nurse to question the order?

Client is disoriented to time and place Clients must be cognitively and physically capable of using the PCA equipment safely. Confusion in a client would lead the nurse to question the client's ability to correctly use the PCA. None of the other listed assessment findings rules out safe use of a PCA.

A nurse is caring for a client who has a tracheostomy tube in place. During tracheostomy care, which of the following should the nurse place underneath the flange of the outer cannula?

Commercially prepared fenestrated dressing: commercially prepared tracheostomy dressing is made of material that does not unravel and has a fenestration (slit) designed to fit around the tracheostomy tube under the flanges. incorrect rationale: Commercially prepared transparent dressing: Tracheostomy dressings should be removed often, and the adhesive backing of a transparent dressing would be too irritating to the client's skin if removed frequently.

A nurse is caring for a client who was admitted with community-acquired pneumonia and has been receiving oxygen therapy for several days. Which of the following findings indicates an adverse effect of oxygen therapy?

Cracks in the oral mucosa: Oxygen, especially when delivered long-term and without sufficient humidification, has a drying effect that can cause cracks in the nasal and oral mucosa. incorrect rationale: Elevated heart rate: Tachycardia, caused by a wide variety of clinical conditions, such as hypoxia, generally increases the body's demand for oxygen. However, it is not an adverse effect of oxygen therapy.

When I palpate around the chest tube insertion site, I hear a crackling sound. What does that mean?

Crackling around the dressing or insertion site is a sign of subcutaneous emphysema (crepitus). This is air that gets trapped in the tissues beneath the skin. A possible cause of this is a poor seal at the chest-tube insertion site.

True or False: Suctioning a patient frequently will prevent mucous production?

False. Suctioning will remove mucous but will not prevent the production of mucous. Frequent suctioning can actually produce more mucous.

A nurse is caring for a client who has dyspnea, slight cyanosis, and a respiratory rate of 28/min. During which of the following phases of the nursing process will the nurse determine that the client has impaired gas exchange?

Diagnosis: During the diagnosis phase, the nurse analyzes and interprets data gathered from the nursing assessment to formulate a nursing diagnosis, which in this case is impaired gas exchange. incorrect rationale: Assessment: During the assessment phase, the nurse collects and verifies data to formulate a database reflecting the client's problems and concerns.

The nurse is preparing to administer an IM injection to a 5-year-old and asks the student working with the child to assist by blowing bubbles for the client while the nurse gives the injection. Which type of pain management is blowing bubbles?

Distraction Distraction techniques aim at shifting a child's focus from pain to another activity or interest. In this case, blowing bubbles serves as a distraction.

What do you do if you walk into your patient's room and find a family member pushing the PCA button?

Educate family and patient. The patient should control their pain medication.

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?

Effective breathing at a rate of 16 breaths/minute through the established airway Explanation: 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.

Oxygen therapy is prescribed for a client who is brought to an emergency department in the early stages of hypoxia. When assessing this client, a nurse should expect which of the following findings?

Elevated blood pressure: During the early stages of hypoxia, blood pressure is usually elevated (unless shock is the cause of the client's hypoxia). In the late stages of hypoxia, clients are likely to develop hypotension. incorrect rationale: Decreased respiratory rate: A declining respiratory rate is a common finding in the late stages of hypoxia. In the early stages, vital sign changes include increases in both the heart and respiratory rates. Cyanosis: Cyanosis, a bluish discoloration of the skin and mucous membranes caused by low oxygen levels in the blood, is a common finding in the late stages of hypoxia. Peripheral edema: Peripheral edema is a sign of chronic hypoxia, which is experienced by clients who have long-standing COPD.

The nurse educator is explaining the difference between indications for nasopharyngeal airway insertion versus endotracheal intubation. Which responses from learners indicate correct reasons for the use of endotracheal tubes in clients? Select all that apply.

Endotracheal intubation is indicated to establish an airway for a client who cannot be adequately ventilated with an oropharyngeal or nasopharyngeal airway, bypass an upper airway obstruction, prevent aspiration, permit connection of the client to a resuscitation bag or mechanical ventilator, or facilitate the removal of tracheobronchial secretions. In the case of potential facial trauma or basal skull fracture, the nasopharyngeal airway should not be used because it could enter the brain cavity instead of the pharynx.

The nurse is caring for a client who is postoperative and has pain that is an 8 on a scale of 0 to 10. There is an order for intravenous pain medication every 4 hours as needed. The nurse administers the prescribed pain medication to the client. What should the nurse do to assist in meeting this client's desired outcome of a pain scale score less than 4 on a scale of 0 to 10?

Evaluate the client's pain level after the appropriate amount of time has elapsed for the pain medication to take effect. Explanation: In the evaluation phase of the nursing process, the nurse measures the extent to which the client has achieved outcomes. This phase helps determine whether the nurse should terminate, continue, or modify the plan of care. To ensure that this client's plan of care is appropriate, the nurse must evaluate the client's response to the intervention of administering pain medication. The nurse must evaluate the results of the intervention that has already been implemented before determining the need to modify the plan of care. Therefore, neither calling the surgeon nor modifying the plan of care is appropriate at this time, and continuing to make rounds on other clients would not address this client's needs specifically.

What if the patient is breathing 10 times per minute. Should I stop the pain medication and give naloxone?

First, wake the patient. Count the respirations again. If the patient arouses easily and talks with clarity, just continue to monitor him. If the patient is difficult to stimulate and does not respond, give the opioid antagonist naloxone (Narcan) as prescribed and with great caution. The recommended initial dose is 0.4 mg diluted in 9 mL of normal saline solution. Slowly push 0.5 mL intravenously over 2 minutes until the patient's respirations improve to an acceptable level and have good depth or prescribed dosage is reached. Be aware that naloxone wears off quickly, sooner than the opioid will. So, assess respiration and sedation frequently and according to your facility's policies and procedures.

The nurse is aware that loss of consciousness occurs with which type of anesthesia?

General - vA therapeutic effect of general anesthesia is loss of consciousness.

My patient tends to develop respiratory distress during suctioning. What should I do when this happens?

Immediately withdraw the suction catheter and administer oxygen and breaths from a manual resuscitation bag as needed. In an emergency, you can deliver oxygen directly through the catheter by disconnecting the suction and attaching oxygen at the prescribed flow rate.

Are there any times when I should strip or milk a chest tube?

In general, avoid any excessive manipulation of the tube unless there is a specific indication and a physician's prescription for stripping or milking, and your facility does not prohibit it. Keep in mind that the use of these practices is not-evidence based, and they can be harmful. Stripping and milking can create additional negative pressure and can injure pleural membranes and tissues. Be sure to check your facility's policy about these techniques.

How far should I insert the catheter when I suction a patient's airway?

Insert the suction catheter until you meet resistance or until the patient coughs. Then pull it back 1 cm (1/2 inch) and slowly withdraw it while applying intermittent suction and using a rotating motion (no more than 15 seconds).

You are caring for a patient who is receiving morphine via a patient-controlled analgesia (PCA) pump. You note that the patient's respiratory rate is 10 breaths per minute. The patient is somnolent, with minimal response to physical stimulation. You should prepare to administer which of the following medications?

Intravenous naloxone (Narcan)

A nurse uses a nasal cannula to deliver oxygen to a client who is extremely hypoxic and has been diagnosed with chronic lung disease. What is the most important thing to remember when using a nasal cannula?

It can cause the nasal mucosa to dry in case of high flow. Explanation: When using a nasal cannula to deliver oxygen to a client, the nurse should remember that the nasal cannula can cause the nasal mucosa to dry in case of high oxygen flow. A simple mask can cause anxiety in clients who are claustrophobic. Clients using a partial rebreather mask are at risk of suffocation. A face tent may deliver an inconsistent amount of oxygen, depending on environmental loss.

If fenestrated gauze is not available, should I cut a 4 x 4 gauze pad and use it as a sterile dressing under a tracheostomy tube's flanges?

It is not safe to cut a gauze pad and use it with a tracheostomy tube. The patient could aspirate fibers from the gauze, resulting in an infection or an abscess in the trachea. Use commercially prepared tracheostomy dressings or a folded 4 x 4 gauze pad instead.

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 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.

A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which of the following delivery devices should the nurse use in order to administer oxygen to the client?

Nasal cannula Simple mask Face tent Non-rebreather mask The nurse should use a nasal cannula to administer oxygen to an asthmatic client who requires a low concentration of oxygen. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It is used for administering a low concentration of oxygen to clients who are not extremely hypoxic and are diagnosed with chronic lung disease. A simple mask allows the administration of higher levels of oxygen than a cannula. A face tent is used for clients with facial trauma and burns. Non-rebreather masks are used for clients requiring a high concentration of oxygen and are critically ill.

Should I clamp my patient's chest tube during transportation to another department?

No, because clamping puts the patient at risk for a tension pneumothorax. It's acceptable to clamp it very briefly when replacing the drainage system or looking for an air leak but not during transportation. Be sure to keep the drainage system upright and below the level of the patient's chest so that it functions properly during transportation and ambulation. Portable suction may be necessary.

Administering oxygen therapy with a nonrebreather mask has which of the following advantages?

Offers the highest oxygen concentration of the low-flow systems: A nonrebreather mask delivers oxygen concentrations of 60% to 80%. Thus, it provides a higher fraction of inspired oxygen (FiO2) than other low-flow systems such as a nasal cannula (delivering about 24% to 44%) or a simple mask (delivering 40% to 60%).

A nurse should recognize that which of the following findings is an indication for oxygen therapy?

Oxygen saturation (SaO2) 90%: Oxygen therapy is indicated for clients who are at risk for or have developed hypoxia. In the early stages of hypoxia, the heart rate increases and the arterial oxygen saturation (SaO2) falls below 94%. incorrect: Respiratory rate 32/min: A client who has a respiratory rate of 32/min is outside the expected reference range of 12 to 20/min. The client is hyperventilating and does not require more oxygen but rather needs more carbon dioxide, which can be obtained by exhaling into and inhaling from a paper bag.

A client being seen in the emergency department has labored respirations. Auscultation reveals inspiratory and expiratory wheezes. Oxygen saturation is 86%. The client was nonresponsive to an albuterol (Ventolin) inhaler and intravenous methylprednisolone (Solu-Medrol). The nurse administers the following prescribed treatment first:

Oxygen therapy through a non-rebreather mask The description is consistent with status asthmaticus. The client has not responded to treatment. Oxygen saturation is low. As oxygenation is the priority per Maslow's hierarchy of needs, oxygen therapy would be supplied first. Then, the nurse would initiate intravenous fluids and magnesium sulfate. Last, the nurse would encourage the client to drink fluids to prevent dehydration.

The nurse is preparing to insert an oropharyngeal airway. Which action would be most appropriate to determine the proper size?

Placing the airway next to the cheek with tip pointing down. Explanation: The nurse determines the correct size by placing it next to the child's cheek with the tip pointing down. An airway that is too large will extend past the angle of the child's mandible and can obstruct the glottic opening when inserted. Measuring the distance from the end of the nose to the tragus of the ear is appropriate for a nasopharyngeal airway. Looking at the child's fifth digit reflects the approximate diameter of the nasopharyngeal airway. Measuring from the tip of the nose to the earlobe to the middle area between the xiphoid process and umbilicus is used to determine the length of a nasogastric tube.

The home health nurse is caring for a homebound client who is terminally ill and is delivering a patient-controlled analgesia (PCA) pump at today's visit. The family members will be taking care of the client. What would the nurse's priority interventions be for this visit?

Provide client and family teaching regarding the operation of the pump, monitoring the IV site, and knowing the side effects of the medication. If PCA is to be used in the client's home, the client and family are taught about the operation of the pump as well as the side effects of the medication and strategies to manage them. The family would also need to monitor the IV site and notify the nurse of any changes, such as infiltration, that could endanger the client. Teaching the family the theory of pain management or the use of alternative therapies and the nurse providing emotional support are important, but the family must be able to operate the pump as well as know the side effects of the medication and strategies to manage them. Offering spiritual guidance would not be a priority at this point and morphine is not the only medication given by PCA.

What should I do if my patient's chest tube detaches from the drainage system?

Quickly submerge the end of the chest tube in 1 inch of sterile water. This helps maintain the seal while you prepare the system for reattachment or replacement. That includes cutting off or disinfecting any potentially contaminated tubing ends.

What would be the steps you would Take for a patient whose SpO2 level is 82% and they are alert?

Raise the HOB Encourage patient to cough and deep breath Obtain order/apply O2 via nasal cannula Continue to monitor/stay with your patient Etc.

A client with asthma has been prescribed low-flow oxygen by nasal cannula at 3 LPM. How should the nurse best determine the correct flow rate?

Refer to a flow meter Explanation: In order to regulate the amount of oxygen delivered to the client, the nurse should use a flow meter. A flow meter is attached to the source of oxygen. Flow rate can not be observed and it is not inferred on the basis of the client's response.

A nurse is caring for a client who has a cuffed endotracheal (ET) tube in place. Which of the following actions should the nurse plan to take?

Repositioning the ET tube in the client's mouth every 12 hr: Moving the ET tube to the other side of the client's mouth every 12 hr (or according to facility policy) helps prevent irritation to the oral mucous membranes.

A nurse is caring for a client who has been receiving oxygen via nasal cannula for 4 hr. Which of the following assessment findings helps indicate that oxygen therapy has been effective?

Respiratory rate 14/min: The expected reference range for respirations is 12 to 20/min. Stabilization of the respiratory rate, especially if the client was previously tachypneic, is an indication that oxygen therapy is effective.

The anesthesiologist will use moderate (conscious) sedation during the client's surgical procedure. The circulating nurse will expect the client to:

Respond verbally during the procedure Clients can respond to verbal and physical stimuli and maintain an oral airway and protective reflexes during moderate sedation.

A nurse is suctioning a client's airway using in-line suctioning. Which of the following actions should the nurse plan to take?

Reuse the catheter repeatedly: With in-line suctioning, the catheter attaches to the ventilator tubing and does not need to be replaced until the system is replaced. It can be used repeatedly. incorrect rationale: Wear a face shield during the procedure: the nurse is not exposed to airway secretions, because the catheter is enclosed in a plastic sheath. Therefore, a face shield is not necessary.

The client was found not breathing and was transported to the hospital. A family member states the client may have taken too much pain medication because the client frequently forgets if the medication was taken. Which observation(s) by the nurse indicates therapeutic effect of naloxone hydrochloride in the client? Select all that apply.

Reverses decreased respiratory rate of 10. Reverses decreased level of consciousness. Reverses blood pressure of 90/58. Therapeutic effect includes reversal of respiratory depression, sedation, and hypotension. Therapeutic effect does not include increasing nerve pain or increasing inflammation.

What are the signs and symptoms of oxygen toxicity?

Signs and symptoms of oxygen toxicity result from its effects on the central nervous system (CNS) and pulmonary system. CNS manifestations of oxygen toxicity include pallor, sweating, nausea, vomiting, seizures, muscle twitching, vertigo, tinnitus, hallucinations, visual changes, anxiety, respiratory changes, and decreased levels of consciousness. Pulmonary signs and symptoms of oxygen toxicity include substernal chest pain, shortness of breath, dry cough, and pulmonary edema or fibrosis.

What supplies are needed to complete bedside trach cleaning cares on my patient with a non-disposable inner cannula?

Sterile kit (gloves, pipe cleaners/Q-tips, 4x4 gauze, split gauze, trach ties, absorbent pad, etc.) Sterile normal saline solution Mask/Face shield Emergency supplies at bedside: Resuscitation bag with mask (Ambu-bag) Extra trach (same size and type) Obturator

A nurse is caring for a client who is receiving morphine via a patient controlled analgesia (PCA) pump. When assessing the client, the nurse notes that the client's respiratory rate is 6 breaths per minute. What should the nurse do first?

Stop the PCA pump. A side effect of morphine is respiratory depression. In this situation, the nurse should first stop the PCA pump and then notify the health care provider. Naloxone is used to reverse the sedative effects of opioids, but this would not be administered before stopping the PCA.

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 Explanation: 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.

What are the 4 phases in the process of nociception?

The basic process of nociception occurs in four phases called transduction, transmission, perception, and modulation. The effects of non-opioids such as ibuprofen (Advil, Motrin) and cortico-steroids interrupt pain at the transduction phase and inhibit pain at the site of injury. Opioids work at the transmission phase of the pain process and bind at different sites. Different individuals need different amounts; you have to titrate each patient's pain medications to achieve effective relief for the individual.

While assessing clients receiving opioid analgesics for pain management, what finding would alert the nurse and require healthcare provider notification?

The client with a pulse of 118, a respiratory rate of 8, and a BP of 80/60 The primary healthcare provider should be contacted if the client's respiratory rate is 10 breaths per minute or less; and/or a significant increase or decrease in the client's pulse rate or quality is observed; and/or a significant decrease in blood pressure (systolic or diastolic) is observed; or a systolic pressure below 100 mm Hg is recorded.

True or false: Sedation occurs before respiratory depression.`

True: Sedation occurs before respiratory depression, thus respiratory compromise is preventable. Monitor sedation carefully in opioid-naïve patients, the very young, the very old, and patients receiving additional medication that causes sedation, such as promethazine (Phenergan) or diazepam (Valium).

Should I be concerned about administering analgesics to patients who have a history of substance abuse?

This is a common fear and a significant barrier to effective pain management. When assessing for pain, remember that the patient is the expert concerning his pain. If you suspect that a patient is seeking drugs, treat the patient as prescribed and then refer the patient according to your facility's protocol for addressing substance abuse. Make sure your assessment is complete and documented. Taking pain medications because the patient needs them does not mean that he is "addicted." Less than 1% of the population later becomes addicted to medications they receive in a hospital. Sure, some people may seek healthcare to obtain drugs, but it is not your responsibility to determine that. And even so, people who are seeking drugs may truly have pain and require pain management. It is also important to understand that some analgesics can cause specific adverse effects in patients who are opioid-dependent.

A nurse is caring for a client who sustained trauma to their head and neck and will require long-term airway support. Which of the following pieces of equipment will be required for home health care for this client?

Tracheostomy tube: Tracheostomy tubes are used for long-term airway support. They are suitable devices for long-term management of airway obstruction. incorrect rationale: Endotracheal tube: Although this client probably had an endotracheal (ET) tube inserted initially, ET tubes are not usually left in place for more than 14 days because doing so places the client at risk for infection and airway injury. Oropharyngeal airway device: This type of airway management device keeps the upper airway patent when it is at risk of becoming obstructed. However, because an oropharyngeal airway stimulates the gag reflex, it can only be used for a client who has an altered level of consciousness. This is not a suitable device for long-term management of airway obstruction. Nasopharyngeal airway device: This type of airway management device keeps the upper airway patent when it is at risk of becoming obstructed by the tongue or by secretions, which is a risk for clients who are unconscious. Howeve

The nurse administers an opioid analgesic to a client. When assessing for therapeutic effects, the nurse will perform which action?

Using a pain scale, ask the client to describe the pain. Explanation: Asking the client to describe the pain using a pain scale is the most effective assessment of pain response and is more accurate than a yes/no question about being in pain. Observing the client when they are unaware is an objective assessment and does not represent a true pain experience. Respiratory assessment focuses on adverse effects, not therapeutic effects.

A client with chronic obstructive pulmonary disease (COPD) requires high-flow oxygen. How should the nurse administer the client's supplementary oxygen?

Venturi mask Explanation: A Venturi mask is a high-flow delivery device while the other listed options are each low-flow devices.

A nurse is caring for a critically ill client who has COPD and requires delivery of a precise concentration of oxygen. Which of the following types of oxygen-delivery devices is indicated for this client?

Venturi mask: A Venturi mask is most often used for critically ill clients who require administration of a specific concentration of oxygen. This is the most accurate form of oxygen delivery and keeps carbon dioxide buildup minimal. incorrect rationale: Nasal cannula: The exact concentration of oxygen inspired through a nasal cannula depends on the flow rate and on the client's rate and pattern of breathing and depth of respiration. This device cannot ensure delivery of a specific concentration of oxygen. Face tent: A face tent is convenient for delivering both humidification and oxygen; however, it is difficult to control the concentration of oxygen administered because it depends on the rate and depth of the client's respirations.

A nurse is performing chest physiotherapy for a client who needs help mobilizing and expectorating thick pulmonary secretions. To increase the turbulence of the air the client exhales, the nurse should use which of the following techniques?

Vibration: Vibration is used during or after percussion to increase the turbulence of exhaled air and loosen secretions. incorrect rationale: Percussion: Percussion involves striking the skin over congested lung fields to dislodge secretions from the bronchial walls. It does not increase air turbulence. Nebulization: Nebulizer therapy is often administered before postural drainage to help loosen secretions, not to increase air turbulence. Postural drainage: Postural drainage allows secretions to drain by gravity from different areas of the lungs. It does not increase air turbulence.

Which guideline describes the proper method for measuring the appropriate length to use when inserting a nasopharyngeal airway?

When holding the airway on the side of the client's face, it should reach from the tragus of the ear to the tip of the nostril. Explanation: The nasopharyngeal airway length is measured by holding the airway on the side of the client's face. The airway should reach from the tragus of the ear to the tip of the nostril. The diameter should be slightly smaller than the diameter of the nostril. For an oropharyngeal airway, when holding the airway on the side of the client's face, it should reach from the opening of the mouth to the back angle of the jaw.

A nurse is preparing to suction a client's oral airway. Which of the following devices or methods should the nurse use?

Yankauer (tonsil tip) suction catheter helps clear secretions from the mouth. This is the appropriate device to use for clients who can cough effectively but cannot swallow or expectorate secretions.

Is an NSAID a better choice than opioids for older patients?

Yes and no. Although they are effective alone or as adjuncts to opioids, nonsteroidal anti-inflammatory drugs (NSAIDs) are more likely to cause gastric and renal toxicity and other potentially serious effects such as cognitive impairment, constipation, and headaches in older patients. And along the same lines, older patients tend to be more sensitive to the analgesic and central nervous system depressant effects of opioids. But they are not contradicted for older patients. Peak opioid effects are often greater and the duration of pain relief may be longer for older patients, thus they may be very effective for managing moderate to severe pain. The guiding principle is that you must monitor your older patients extremely carefully when they are receiving analgesic medications of any type.

Is a provider's order required to administer oxygen therapy?

Yes it is, as the administration of oxygen can have potent effects on the patient. Treat oxygen therapy as you would a medication, applying the rights of medication administration. Check the provider's orders to verify that the patient is receiving the correct dosage or concentration of oxygen and note any parameters for adjustment

A client involved in a car accident is admitted with a chest tube following pneumothorax. He also has an elevated blood alcohol level. When the nurse enters his room, she notes the client is dyspneic, short of breath, and holding his chest tube in his hand. When the nurse pulls the linens back, she finds a "sucking" chest wound. After calling a "code blue," the next priority intervention would be to:

apply a Vaseline gauze (airtight) dressing over the insertion site. Explanation: The client has a medical emergency. Sucking chest wounds, which allow air to pass in and out of the chest cavity, should be treated by promptly covering the area with an airtight covering. Chest tubes are inserted as soon as possible. The other interventions will not help minimize the amount of air entering the pleural space.

After total hip replacement, a client is receiving epidural analgesia to relieve pain. Which action is a nursing priority for this client?

assessing for sensation in the legs For epidural analgesia, a catheter is placed outside the dura mater in the epidural space. Catheter displacement, which may cause spinal injury, is signaled by loss of motion and sensation in the legs. Therefore, the nurse should assess closely for sensation and ask about numbness of the legs. The nurse should change the catheter site dressing every day or every other day. Capillary refill time has no bearing on epidural analgesia. A client with an epidural catheter may ambulate and need not be confined to bed.

Which assessment factors would indicate a need for oropharyngeal suctioning?

breathing rate of 36 breaths/min and noisy, gurgling respirations oxygen saturation levels of 95% and diaphragmatic breathing patterns auscultation of crackles in the lower lobes of the lungs thin sputum, weak cough, and enlargement of the tonsils An increase in the breathing rate indicates hypoxia in the body. The signs of noisy, gurgling respirations indicate airway interference and the need for suctioning. Clients should be able to cough up thin sputum, and tonsil enlargement should not interfere. Crackles in lower lobes signify lung congestion, not airway impairment. Oxygen saturation levels of 95% are normal.

An adult client is discharged to home with a prescription for oxygen at 2 L/min. Which method of oxygen delivery should the nurse use in this situation?

nasal cannula Explanation: A nasal cannula is commonly used because it does not impede eating or speaking and is easily used in the home. A mask is used when a client requires a higher concentration of oxygen than a nasal cannula can deliver or if the client is a mouth breather. Oxygen hoods and tents are generally used to deliver oxygen to infants and children.

A nurse is caring for a client who has a tracheostomy tube with an inner cannula in place. Which of the following supplies should the nurse use to dry the inner cannula of the client's tracheostomy tube after cleaning it?

folded pipe cleaners: The nurse should use pipe cleaners to dry the inner cannula after cleaning because they remain intact without leaving any particulate matter the client could aspirate.

A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which delivery device should the nurse use in order to administer oxygen to the client?

nasal cannula Explanation: The nurse should use a nasal cannula to administer oxygen to an asthmatic client who requires a low concentration of oxygen. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It is used for administering a low concentration of oxygen to clients who are not extremely hypoxic and are diagnosed with chronic lung disease. A simple mask allows the administration of higher levels of oxygen than a cannula. A face tent is used for clients with facial trauma and burns. Nonrebreather masks are used for clients requiring a high concentration of oxygen and who are critically ill.

Nociceptive pain

pain that arises from damage to or inflammation of tissue other than that of the peripheral and central nervous systems can be somatic (musculoskeletal) or visceral (internal organ)

Somatic pain

pain that originates from bone, joints, connective tissues, muscles and skin. Can be sharp and localized or dull and generalized

visceral pain

pain that originates from thoracic, pelvic, or abdominal organs and care radiate in several directions

Neuropathic pain

pain that results from injury to neurons and causes CNS to process sensory input abnormally

The client is 65-years-old and has a diagnosis of cancer. Morphine has been ordered for pain management. Before the administration of morphine, the initial action of the nurse would be to check which?

respiratory rate, depth, and rhythm. The most hazardous adverse effects of morphine relate to excessive CNS depression and include respiratory depression, hypoventilation, apnea, respiratory arrest, circulatory depression, cardiac arrest, shock, and coma. The most frequent adverse effect of morphine is respiratory depression. The nurse's initial action should be to check the client's respiratory rate, depth, and rhythm. Morphine should not be administered to any client with respiratory depression because it may precipitate respiratory arrest. Heart rate, blood pressure, and temperature are important and should be assessed, but doing so would not be the initial action of the nurse.

The nurse is caring for a client who has a percutaneous tracheostomy (PCT) following a skydiving accident. Which oxygen delivery device will the nurse select?

tracheostomy collar Explanation: A tracheostomy collar delivers oxygen near an artificial opening in the neck. This is appropriate for a client who has had a PCT. Other devices are not appropriate for this client.