Care of Patients Requiring Oxygen Therapy or Tracheostomy

The patient is receiving warmed and humidified oxygen. In discarding the moisture formed by condensation, why does the nurse minimize the time that the tubing is disconnected? a. To prevent the patient from desaturating b. To reduce the patient's risk of infection c. To minimize the disturbance to the patient d. To facilitate overall time management

a. To prevent the patient from desaturating

Care issues for the Patient with a Tracheostomy.

-Tissue damage can occur at the point where the inflated cuff presses against the tracheal mucosa. -Mucosal ischemia occurs when the pressure exerted by the cuff on the mucosa exceeds the capillary perfusion pressure. -To reduce the risk for tracheal damage, keep the cuff pressure between 14 and 20 mm HG or 20 and 30 cm H20.

Air Warming & Humidification

-Tracheostomy tube bypasses nose & mouth, which normally humidify, warm, & filter air. -Air must be humidified. -Maintain proper temp. -Ensure adequate hydration.

Weaning from a Tracheostomy Tube

-Weaning- gradual decrease in tube size; ultimate removal of tube. -Cuff is deflated when patient can manage secretions; does not need assisted ventilation. -Tube may be removed after he or she tolerates more than 24 hours of capping. -Change from cuffed to uncuffed tube. -Tracheostomy button has potential danger of getting dislodged.

The patient requires long-term airway maintenance following surgery for cancer of the neck. The nurse is using a piece of equipment to explain the procedure nd mechanism that are associated with this long-term therapy. Which piece of equipment does the nurse most likely use for this patient teaching session? a. Tracheostomy tube b. Nasal trumpet c. Endotracheal tube d. Nasal cannula

a. Tracheostomy tube

A patient with a tracheostomy is unable to speak. He is not in acute distress, but is gesturing & trying to communicate with the nurse. Which nursing intervention is the best approach in this situation? a. Rely on the family to interpret for the patient b. Ask questions that can be answered with a "yes" or "no" response c. Obtain an immediate consult with the speech therapist d. Encourage the patient to rest rather than struggle with communication.

B

A patient with a tracheostomy tube is currently alert & cooperative but seems to be coughing more frequently & producing more secretions than usual. The nurse determines that there's a need for suctioning. Which nursing intervention does the nurse use to prevent hypoxia for this patient? a. Allow the patient to breathe room air prior to suctioning b. Avoid prolonged suctioning time c. Suction frequently when the patient is coughing d. Use the largest available catheter

B

The home health nurse has been caring for a patient with a chronic respiratory disorder. Today the patient seems confused when she is normally alert & oriented x3. What is the priority nursing action? a. Notify the physician about the mental status change. b. Take vital signs & check the pulse ox readings. c. Ask the patient's family when this behavior started. d. Perform a mental status exam.

B

The nurse is caring for several patients on a general medical-surgical unit. The nurse would question the necessity of oxygen therapy for a patient with which condition? a. Pulmonary edema with decreased arterial Po2 levels. b. Valve replacement with increased cardiac output. c. Anemia with a decreased hemoglobin and hematocrit. d. Sustained fever with an increased metabolic demand.

B

Which conditions can increase the body's need for more oxygen? (Select all that apply) a. Hypothroid b. Sickle cell disease c. Infection in the blood d. Body temperature of 101 F e. Arterial blood gas results

B,C,E

Bronchial & Oral Hygiene

-Bronchial hygiene promotes a patent airway & prevents infection. -Oral hygiene is important to keep the airway patent, to prevent bacterial overgrowth, & dental caries & to promote comfort. -Oral secretions can move down the trachea & collect about the inflated cuff of the endotracheal tube. When the cuff is deflated the secretions can move into the lungs. -Turn/reposition every 1 to 2 hours, support out of bed activities, encourage early ambulation. -Coughing & deep breathing, chest percussion, vibration, & postural drainage promote pulmonary care. -Avoid glycerin swabs or mouthwash containing alcohol for oral care; assess for ulcers, bacterial/fungal growth, infection.

Hazards & Complications of Oxygen Therapy

-Combustion -Oxygen-induced hypoventilation -Oxygen toxicity= is related to the concentration of oxygen delivered, duration of oxygen therapy, & degree of lung disease present. Symptoms include: dyspnea, nonproductive cough, chest pain beneath the sternum, & GI upset. Symptoms become more severe: decreased vital capacity, decreased compliance, crackles, & hypoxemia. Atelectasis, pulmonary edema, hemorrhage, & hyaline membrane formation result. -Absorption atelectasis- new onset of crackles/ decreased breath sounds. Nitrogen prevents alveolar collapse because it does not cross the alveolar capillary membranes & remains in the airways & alveoli. Drying of mucous membranes- Infection

Tracheostomy Tubes

-Disposable or reusable -Cuff or no cuff -Cuffed tube doesn't protect against aspiration. Have a cuffed tube inflated may give a false sense of security that aspiration can't occur during feeding or mouth care. -Fenestrated tube- when inner cannula is in place, the fenestration is covered over (closed) & this tube works like a double-lumen tube. *ACTION ALERT*- Always deflate the cuff before capping the tube with the decannulation cap; otherwise, the patient has no airway.

Suctioning

-Maintains a patent airway & promotes gas exchange by removing secretions when the patient can't cough adequately. -Suctioning is needed when secretions are audilble or noisy, when crackles or wheezes are heart on auscultation, or when restlessness, increased pulse or respiratory rates, or mucus in the artificial is present. -Done through nose or mouth. -Can cause hypoxia, tissue (mucosal) trauma, infection, vagal stimulation, bronchospasm, & cardiac dysrhythmias. -Hypoxia: ineffective oxygenation before, during, & after suctioning. Use of a catheter that's to large for artificial airway; prolonged suctioning time; excessive suction pressure; too frequent suctioning. Oxygen saturation below 90% by pulse ox. indicates hypoxemia. -Tissue trauma- results from frequent suctioning, prolonged suctioning time, excessive suction pressure & nonrotation of the catheter. -Infection- because each catheter pass introduces bacteria into the trachea. -Vagal stimulation & bronchospasm- VS results in severe bradycardia, hypotension, heart block, v-tach, asystole. B- occurs when the catheter passes into the airway.

Ensuring Nutrition

-Swallowing can be a major problem for patients with trach. tube. - If balloon is inflated, can interfere with passage of food through the esophagus. -Elevate HOB for at least 30 minutes after eating to prevent aspiration during swallowing. -Avoid serving meals when patient is fatigued. -Provide smaller & frequent meals. -Adequate time do not "hurry" -Emergency suctioning equipment -Avoid water & other "thin" liquids -Thicken all liquids -When possible, completely deflate the tube cuff during meals. -Suction after initial cuff deflation to clear the airway & allow maximum comfort. -Encourage patient to dry swallow after each bite to clear residue from the throat.

Tracheostomy Care

1. Assemble necessary equipment. 2. Wash hands. Standard precautions. 3. Suction trach. tube if necessary. 4. Remove old dressings & excess secretions. 5. Set up sterile field. 6. Remove & clean inner cannula. Use half-strength hydrogen peroxide to clean the cannula & sterile saline to rinse it. 7. Clean the stoma site & then the tracheostomy plate with half-strength hydrogen peroxide followed by sterile saline. 8. Change trach. ties if they are soiled. Secure new ties in place before removing soiled ones to prevent accidental decannulation. If a knot is needed tie a square knot that's visible on the side of the neck. One or two fingers should be able to be placed between the tie tape.

Priority Patient Problems

1. Reduced oxygenation related to weak chest muscles, obstruction, or other physical problems. 2. Inadequate communication related to tracheostomy or intubation. 3. Inadequate nutrition related to presence of endotracheal tube. 4. Potential for infection related to invasive procedures. 5. Damaged oral mucosa related to mechanical factors (endotracheal tube).

A patient with a tracheostomy who receives unnecessary suctioning can experience which complications? (Select all that apply). a. Bronchospasm b. Mucosal damage c. Impaired gag reflex d. Bronchodilation e. Bleeding

A B E

What are the hazards of administering oxygen therapy? (Select all that apply) a. Oxygen supports and enhances combustion. b. Oxygen itself can burn. c. Each electrical outlet in the room must be covered if not in use. d. All electrical equipment in the room must be grounded. e. Solutions with high concentrations of alcohol or oil cannot be used in the room.

A D E

At what times is oxygen therapy needed for a patient? (Select all that apply) a. To treat hypoxia. b. To treat hypothermia c. To treat hypoxemia d. When the normal 35% oxygen level in the air is inadequate. e. When the normal 21% oxygen level in the air is inadequate.

A, C, E

The client is being discharged home with a tracheostomy. Which statement by the client indicates the need for further teaching about tracheostomy care? A. "I can only take baths, no showers." B. "I can put normal saline in my tracheostomy to keep the secretions from getting thick." C. "I should put cotton or foam over the tracheostomy hole." D. "I will have to learn to suction myself."

A. "I can only take baths, no showers." The client does not understand that he can shower with the use of a shower shield over the tracheostomy tube to prevent water from entering the airway. Additional teaching is necessary.

A client with COPD has a physician's prescription stating, "Adjust oxygen to SpO2 at 90% to 92%." Which nursing action can be delegated to a nursing assistant working under the supervision of an RN? A. Adjust the position of the oxygen tubing B. Assess for signs and symptoms of hypoventilation C. Change the O2 flow rate to keep SpO2 as prescribed D. Choose which O2 delivery device should be used for the client

A. Adjust the position of the oxygen tubing The scope of a nursing assistant's work includes positioning of oxygen tubing for client comfort.

Which client has the most urgent need for frequent nursing assessment? A. An older client who was admitted 2 hours ago with emphysema and dyspnea and has a 45-year 2-pack-per-day smoking history, and is receiving 50% oxygen through a Venturi mask B. A young client who has had a tracheostomy for 1 week, who is on room air with SpO2 in the upper 90's, who has been receiving antibiotic therapy for 16 hours, and who has foul-smelling drainage on the tracheostomy ties C. An older adult client who is anxious to go home with her new tank of oxygen and supply of nasal cannulas and is being discharged with a new prescription for home oxygen therapy D. A middle-aged client who was admitted yesterday with pneumonia and is receiving oxygen at 2 L/min through a nasal cannula

A. An older adult client who was admitted 2 hours ago with emphysema and dyspnea and has a 45-year 2-pack-per-day smoking history, and is receiving 50% oxygen through a Venturi mask An older adult client with a long history of smoking and chronic lung disease who is receiving high-flow oxygen delivery is at elevated risk for respiratory depression owing to the hypoxic drive of respirations countered by high levels of oxygen. This client must be assessed frequently while receiving high-flow oxygen.

The peak pressure alarm is sounding on the ventilator of the client with a recent tracheostomy. What intervention should be done first? A. Assess the client's respiratory status B. Decrease the sensitivity of the alarm C. Ensure that the connecting tubing is not kinked D. Suction the client

A. Assess the client's respiratory status The client must always be assessed before attention is turned to equipment.

A (DNR) client has a non-rebreather oxygen mask and breathing appears to be labored. What does the nurse do first? A. Ensures that the tubing is patent and that oxygen flow is high B. Notifies the chaplain and the family member of record C. Calls the Rapid Response Team and prepares to intubate D. Comforts the client and confirms that signed DNR orders are in the chart

A. Ensures that the tubing is patent and the oxygen flow is high Labored breathing and ultimately suffocation can occur if the reservoir bag kinks, or if the oxygen source disconnects or is not set to high flow levels.

For client safety and quality care, which technique is best for the nurse to use when suctioning the client with a tracheostomy tube? A. Hyperoxygenate before and after suctioning B. Repeat suctioning until the tube is clear C. Apply suction during insertion of the tube D. Suction for 30 seconds

A. Hyperoxygenate before and after suctioning The client should be preoxygenated with 100% oxygen for 30 seconds to 3 minutes to prevent hypoxemia. After suctioning, the client should be hyperoxygenated for 1-5 minutes, or until the client's baseline heart rate and oxygen saturation are within normal limits.

An RN from the orthopedic unit has been floated to the medical unit. Which client assignment for the floated RN is best? A. The client with a resolving pulmonary embolus who is receiving oxygen at 6 L/min through a nasal cannula B. The client with chronic lung disease who is being evaluated for possible home oxygen use C. The client with a newly placed tracheostomy who is receiving oxygen through a tracheostomy collar D. The client with chronic bronchitis who is receiving oxygen at 60% through a Venturi mask

A. The client with a resolving pulmonary embolus who is receiving oxygen at 6 L/min through a nasal cannula Orthopedic nurses are familiar with pulmonary emboli and with administration of oxygen through nasal cannulas.

A client has a new tracheostomy and is receiving 60% oxygen via tracheostomy collar. Which assessment finding requires immediate action by the nurse? a. Constant, nonproductive coughing b. Blood-tinged sputum c. Rhonchi in upper lobes d. Dry mucous membranes

ANS: A Causes and manifestations of lung injury from oxygen toxicity include nonproductive cough, substernal chest pain, GI upset, and dyspnea. Blood-tinged sputum is expected in clients with new tracheostomies. Rhonchi in upper lobes indicates sputum that can be expectorated and is not an emergent problem. Dry mucous membranes should be lubricated, and the client's hydration status can be checked.

The nurse assesses a client with a new tracheotomy, and the tracheostomy tube is pulsating in synchrony with the client's heartbeat. Which is the nurse's priority action? a. Notify the health care provider immediately. b. Stabilize the tube by reapplying the ties. c. Change the inner cannula of the tube. d. Increase the inflation pressure of the cuff.

ANS: A If a tracheostomy tube is pulsating with the client's heart rate, this could indicate proximity to the innominate artery and may cause erosion of the artery if left in this position. The provider should be notified immediately. Reapplying the ties, changing the inner cannula, and increasing the inflation pressure of the cuff are all interventions that will not solve the immediate problem of proximity of the tube to the innominate artery.

A client is receiving oxygen via Venturi mask at 40%. On assessment the nurse finds the client cyanotic with labored respirations. Which action does the nurse perform first? a. Remove bedding from around the adaptor opening. b. Listen to lung sounds and obtain a respiratory rate. c. Call respiratory therapy to check oxygen saturation. d. Notify the provider or Rapid Response Team immediately.

ANS: A The Venturi mask works by drawing in a specific amount of air to mix with the oxygen through holes in an adaptor fitted at the bottom of the mask. Holes of different sizes allow different amounts of room air to be entrained, changing the amount of oxygen delivered. Bedding (or clothing) wrapped around those holes would effectively change the FiO2. The nurse should ensure that the holes remain unobstructed. Other options are appropriate but are not the first choice, because this simple step may be what solves the problem.

The nurse is teaching a client about his fenestrated tracheostomy tube. Which statement by the client indicates an accurate understanding of the tube? a. "I'm glad I will still be able to talk with this tube in place." b. "It is great that this tube does not have to be cleaned regularly." c. "This tube will not get dislodged because it never needs suctioning." d. "Because I can't swallow, I will need another tube for eating."

ANS: A The client can speak with a fenestrated tube, which has a hole in it and allows air to flow over the vocal cords. The tube still needs to be cleaned and suctioned. The tube may become dislodged, and the client is able to swallow.

The patient is receiving humidified oxygen which places the patient at high risk for which nursing diagnosis? a. Risk for injury related to the moisture in the tube b. Risk for infection related to the condensation in the tubing c. Impaired physical mobility related to reliance on equipment d. Risk for impaired skin integrity related to the mask

b. Risk for infection related to the condensation in the tubing

Which interventions help to prevent aspiration during eating for a client with a tracheostomy? (Select all that apply.) a. Provide close supervision for the client during eating and drinking. b. Add liquids to foods to make them thinner and easier to swallow. c. Inflate the tracheostomy cuff tube to maximum pressure before starting. d. Let the client indicate readiness for another bite when being fed. e. Have the client tuck the chin down and forward while swallowing. f. Instruct the client to dry swallow to clear food particles from the throat. g. Place the client in a semi-Fowler's position for an hour after eating.

ANS: A, D, E, F The client with a tracheostomy will require close supervision, even if the client is feeding himself or herself. Do not rush the client. Allow him or her to indicate when ready for another bite. Teaching interventions should include instructing the client to tuck the chin down and forward while swallowing to encourage food to move down smoothly. Dry swallowing helps remove food residue. Food may actually become easier to aspirate if it is thinner in texture. The nurse should not initiate adding air to inflate the cuff of a tracheostomy tube further without a physician's order; if possible, the cuff should be deflated during eating. Placing the client in a semi-Fowler's position after the meal will not prevent aspiration.

A client receiving high-flow oxygen has new crackles and diminished breath sounds since the last assessment 1 hour ago. Which action by the nurse is most appropriate? a. Call respiratory therapy and request a bronchodilator treatment. b. Instruct the client to use the spirometer and to cough and deep breathe. c. Consult with the health care provider and request an order for diuretics. d. Ensure that the ordered FiO2 is what is being provided.

ANS: B A client who is receiving high rates of oxygen is at risk for absorption atelectasis, in which the normal nitrogen in the air becomes diluted and the alveoli collapse. Hallmarks of this condition include new onset of crackles and diminished breath sounds. Spirometer use, coughing, and deep-breathing exercises would help to re-expand the alveoli. None of the other options are appropriate choices.

A client who is receiving continuous oxygen therapy by nasal cannula for an acute respiratory problem is becoming increasingly confused. What does the nurse do first? a. Notify the health care provider. b. Assess the client's pulse oximetry. c. Document the observation. d. Raise the head of the bed.

ANS: B Cerebral hypoxia is a cause of confusion and is a sensitive indicator that the client needs more oxygen. Although you would want to notify the provider of the change in the client's condition, the best action is first to assess pulse oximetry and then to increase the oxygen. You would not just document the assessment finding without intervening. Raising the head of the bed would not help the client oxygenate better.

A client has been brought in by the rescue squad to the emergency department. The client is having an acute exacerbation of chronic obstructive pulmonary disease (COPD) and is severely short of breath. On arrival, the client is on 15 L/min of oxygen via rebreather mask. Which action by the nurse takes priority? a. Immediately reduce the oxygen flow to 2 to 4 L/min via nasal cannula. b. Perform a thorough respiratory assessment and attach pulse oximetry. c. Call the laboratory to obtain arterial blood gases as soon as possible. d. Obtain a stat chest x-ray, then slowly wean the client's oxygen down.

ANS: B Oxygen-induced hypoventilation can occur in clients with chronically elevated PCO2 levels, such as those seen in COPD. Giving oxygen can eliminate their hypoxic drive to breathe and can cause respiratory arrest. However, hypoxemia is a greater threat to an acutely ill client than is the potential for oxygen-induced hypoventilation, and clients should be given the amount of oxygen they require. The nurse should perform a thorough respiratory assessment and should monitor the client for signs of this problem, rather than automatically reducing oxygen delivery. Blood gases and a chest x-ray will also be obtained, but they do not take priority over assessing and monitoring the client.

A family member has been taught to provide oral care to a client with a tracheostomy. Which statement by the family member indicates an accurate understanding of the correct way to provide mouth care? a. "I can use glycerin swabs." b. "I'll use water and a toothette." c. "I can use hydrogen peroxide." d. "It is okay to use mouthwash."

ANS: B The best choice for mouth care is water and a toothette because these are the least irritating. Glycerin swabs, hydrogen peroxide, and mouthwash all are too irritating to the mucous membranes of the mouth.

A client is being discharged with a tracheostomy and voices concern about his appearance. What discharge teaching will assist the client with maintaining a positive body image? a. "Tell people how sick you were when they ask about the tracheostomy." b. "Your clothing can help hide the tracheostomy so it is not as noticeable." c. "You can put a bandage around your tracheostomy so no one will see it." d. "You have to ignore comments that people make about your appearance."

ANS: B The client may have an alteration in body image because of the tracheostomy stoma. Encourage the client to wear loose-fitting shirts and collars to help hide the appearance of the stoma. Clients should not be encouraged to tell people about their illness, because they should not be made to "justify" their appearance. You should not bandage the tracheostomy, because airflow would be impaired. Ignoring comments will not help the client's self-image.

The nurse is preparing to receive a postoperative client who just had a tracheostomy. Which action by the nurse takes priority? a. Obtain report from the postanesthesia care unit. b. Place a second tracheostomy tube and obturator at the bedside. c. Review orders for postoperative pain medications. d. Order supplies for tracheostomy care for 24 hours.

ANS: B The nurse must ensure that a second tracheostomy tube with obturator is available at the bedside in case of accidental decannulation, because tube dislodgment in the first 72 hours is an emergency. Obtaining report and understanding pain medication orders are important for any postoperative client, but for the tracheostomy client, having the extra material on hand is critical. Obtaining supplies for tracheostomy care is not as high a priority as the other three.

A client is being weaned from a tracheostomy tube and has tolerated capping of the tube for 24 hours. Which action by the nurse is most appropriate? a. Collect all materials needed for suturing the stoma shut. b. Place a dry dressing over the stoma and tape it securely. c. Assess the client for air leaking around the tube. d. Select a smaller tracheostomy tube to be inserted.

ANS: B The tube will be able to be removed after the client has tolerated capping of it for 24 hours. Therefore, a dry dressing will be able to be placed over the stoma. The stoma will not be sutured. It will heal on its own with a small scar. Airflow should be adequate around the capped tube. The physician will not likely insert the next smallest size tube but instead will remove the existing tube.

A client is being discharged home with a tracheostomy. Which action does the nurse teach the client to decrease the risk for aspiration while eating? a. Swallow quickly. b. Thicken all liquids. c. Rinse all food with water. d. Chew food completely.

ANS: B Thickening liquids may assist the client in swallowing and may help prevent aspiration. Swallowing quickly will not decrease the risk of aspiration and may actually put the client at greater risk. It is not recommended that the client drink water to wash down food. Chewing food completely will help prevent choking but will not decrease aspiration risk.

The nursing student is performing tracheostomy care on a client. Which action by the student leads the supervising nurse to intervene? a. Using folded gauze dressings on both sides of the stoma b. Cutting a slit in a gauze 4 × 4 pad to fit around the stoma c. Applying new tracheostomy ties before removing old ones d. Tying the twill tape in a square knot on the side of the neck

ANS: B Tracheostomy dressings should be made from gauze pads with a manufactured slit in them that fits around the tube. If none are available, use two gauze pads folded in half placed on either side of the tube. Cutting a piece of gauze could result in entry of tiny shreds of the gauze the tracheostomy. The other interventions are appropriate.

A client is 24 hours postoperative after a tracheostomy has been performed. The nurse finds the client cyanotic, with the tracheostomy tube lying on his ch a. Auscultate breath sounds bilaterally. b. Ventilate with a resuscitation bag and mask. c. Call a code or the Rapid Response Team. d. Insert a new obturator into the neck.

ANS: B Tube dislodgment in the first 72 hours after surgery is an emergency because the tracheostomy tract has not matured and replacement is difficult. First, ventilate the client using a manual resuscitation bag and facemask while another nurse calls for help. Although auscultation of breath sounds is important, the client's airway must be opened and ventilation started. Ventilation should begin while another nurse calls the code. Reinsertion of a fresh tracheostomy tube will require the physician's intervention.

The nurse assesses a client who is receiving oxygen via a partial rebreather mask. Which assessment finding does the nurse intervene to correct? a. The bag is two thirds inflated during inhalation. b. The client's pulse oximetry reading is 93%. c. The oxygen flow rate is 2 L/min. d. The arterial oxygen level is 90%.

ANS: C Flow rate should be 6 to 11 L/min. A flow rate of 2 L/min will not adequately inflate the bag. A bag that is two thirds inflated is desired. A pulse oximetry reading of 93% and higher is adequate, as is an arterial oxygenation of 90%.

To prevent accidental decannulation of a tracheostomy rube, what does the nurse do? a. Obtain an order for continuous upper extremity restraints b. Secure the tube in place using ties or fabric fasteners c. Allow some flexibility in motion of the tube while coughing d. Instruct the patient to hold the tube with a tissue while coughing

b. Secure the tube in place using ties or fabric fasteners

The nurse is caring for a client with a new tracheostomy. Which assessment finding requires the nurse's immediate action? a. Cuff pressure readings consistently between 14 and 20 mm Hg. b. Need to change Velcro tube holders three times in 1 day. c. Crackling sensation around the neck when skin is palpated. d. Small amount of bleeding around the incision for the first few days.

ANS: C Subcutaneous emphysema occurs when an opening or tear occurs in the trachea and air escapes into fresh tissue planes of the neck. Air can also progress through the chest and other tissues into the face. Inspect and palpate for air under the skin around the new tracheostomy. If the skin is puffy and you can feel a crackling sensation, notify the physician immediately. Cuff pressures should be maintained between 14 and 20 mm Hg or between 20 and 28 cm H2O. Tracheostomy ties need to be changed at least once a day or whenever soiled. It is not uncommon for a client with a new tracheostomy to have heavy secretions that would necessitate changing them. It is not unusual to have a small amount of bleeding around the incision for the first few days after surgical placement.

A client is to be discharged home on oxygen therapy. What information does the nurse teach the client? a. "Carry the H cylinder tank on short trips." b. "Only use the E tank when stationary." c. "The D or C cylinder can be carried." d. "Roll the tank gently when transporting."

ANS: C The D and C cylinders are small enough to be carried. The H cylinder cannot be carried. The E tank can be transported. The tanks should not be rolled and should be carried only in a stand or a rack.

Which statement by a client indicates an accurate understanding of home self-care of a tracheostomy? a. "The stoma should be left uncovered during the day to dry." b. "I need to put normal saline in my airway twice daily." c. "While showering, I need to keep water out of my airway." d. "I don't need to use tracheostomy ties on a daily basis."

ANS: C The client should put a shield over the tracheostomy to keep water from entering the airway. The airway should remain covered during the day with cotton or foam. Saline should be put in the airway 10 to 15 times daily. Tracheostomy ties should be used daily.

A client requires oxygen received via a face mask but wants to remain as mobile as possible once discharged home. Which intervention by the home health nurse best provides the client with maximal mobility? a. Arrange a consultation with pulmonary rehabilitation to decrease oxygen needs. b. Encourage the client to remove the mask occasionally to assess tolerance. c. Add extra connecting pieces of tubing to the client's existing oxygen setup. d. Change the face mask to a nasal cannula occasionally, such as at mealtimes.

ANS: C To increase mobility, up to 50 feet of connecting tubing can be used with connecting pieces. A client with a chronic respiratory condition needing home oxygen may not be able to decrease oxygen needs through pulmonary rehabilitation, but that would not increase mobility with an oxygen device. The nurse should not independently encourage the client to remove the mask for periods of time or change to a cannula.

A client is becoming frustrated because of an inability to communicate with a tracheostomy. Which intervention by the nurse most effectively enhances communication? a. Explain to the client that speech will be clear and distinct with a fenestrated tube. b. Reassure the client that in time he or she will get used to the speech difficulties. c. Place a sign above the client's bed indicating that the client cannot speak. d. Provide the client with a communication board and call light within easy reach.

ANS: D A communication board and the call light will reassure the client that needs will be communicated and met. It is doubtful that the client with a tracheostomy will ever speak clearly and distinctly, no matter what type of tube he or she uses. Reassuring the client that he or she will get used to the speech difficulties does nothing to alleviate the discomfort and fear associated with impaired communication. Placing a sign above the client's bed indicating that he cannot speak will not enhance his ability to communicate, although it may help staff remember that the client has impaired communication.

The nurse assesses a client during suctioning. Which finding indicates that the procedure should be stopped? a. Heart rate increases from 86 to 102 beats/min. b. Respiratory rate increases from 16 to 20 breaths/min. c. Blood pressure increases from 110/70 to 120/80 mm Hg. d. Heart rate decreases from 78 to 40 beats/min.

ANS: D A decrease in heart rate indicates that the client is not tolerating the procedure, and the vasovagal reflex may be stimulated. An increase in heart rate may be stimulated by suctioning and is expected, as is a slight increase in blood pressure. A slight increase in respiratory rate after the procedure might be caused by the feeling of oxygen being suctioned from the client's airway, along with secretions.

The nurse is caring for a client with orders for oxygen at 5 L/min. Approximately how much FiO2 is the client receiving? a. 24% b. 28% c. 36% d. 40%

ANS: D A nasal cannula can provide oxygen at 0.5 to 6 L/min, corresponding to an FiO2 range of 25% to 40%. At 5 L/min, the client is receiving 40% oxygen.

The nurse observes a nursing student suctioning a client. Which intervention by the student nurse requires the supervising nurse to intervene? a. Checking oxygen saturation post suctioning b. Hyperoxygenating the client after removal of the catheter c. Applying intermittent suction during catheter removal d. Applying suction when the catheter is inserted

ANS: D Applying suction as the catheter is introduced allows the tubing to adhere to the airway and destroys cells. The other options are appropriate actions on the part of a nurse or student who is suctioning a client.

While suctioning a client who had a tracheostomy placed 4 days ago, the nurse notes particles of food in the tracheal secretions. Which action by the nurse is most appropriate? a. Increase the inflation pressure in the tracheostomy cuff. b. Add blue dye to a beverage to assess for aspiration. c. Make the client NPO and notify the health care provider. d. Perform a more thorough assessment of the client.

ANS: D Before calling the provider, the nurse needs more data, such as lung sounds, presence of cough, pulse oximetry reading, and possibly mental status. The nurse could temporarily make the client NPO while conducting this assessment, but calling the provider must wait until he or she has more complete data. The nurse should not decide to increase the inflation pressure in the tracheostomy cuff on his or her own. Adding dye to food, drink, or tube feeding formulas was commonly done in the past but should be avoided because the dye is toxic to lung tissues if aspirated.

A client has been placed on 6 L of humidified oxygen via nasal cannula. Which action by the nurse is most appropriate? a. Drain condensation back into the humidifier, maintaining a closed system. b. Keep the water sterile by draining it from the water trap back into the humidifier. c. Turn down the humidity when condensation begins to collect in the tubing. d. Remove condensation in the tubing by disconnecting and emptying it appropriately.

ANS: D Condensation often forms in the tubing when a client receives humidified high-flow oxygen. Remove this condensation as it collects by disconnecting the tubing and emptying the water. Some humidifiers and nebulizers have a water trap that hangs from the tubing so the condensation can be drained without disconnecting. To prevent bacterial contamination, never drain the fluid back into the humidifier or the nebulizer. Do not turn down the humidity because the physician has ordered it and the client needs it. Minimize how long the tubing is disconnected because the client does not receive oxygen during this period.

The nurse is teaching a family member how to suction the client's tracheostomy at home. Which information does the nurse include in the teaching plan? a. Always suction using sterile technique. b. Suction the mouth first and then the airway. c. Be prepared to recannulate the tube frequently. d. Suctioning with clean technique is acceptable.

ANS: D The family member can suction using clean technique because fewer organisms are present in the home than in the hospital. Never suction the mouth first because airway pathogenic organisms could be introduced into the airway. The family member should not be required to recannulate the tube except in an emergency.

Providing Tracheostomy Care

Assess patient before care. The need for suctioning & trach. care is determined by the amount & consistency of secretions, the specific pulmonary disease, the ability of the patient to cough & deep breathe, the need for mechanical ventilation & wound care. -Secure trach tubes in place (IT IS CRITICAL)!!

Respiratory Assessment

Arterial blood gas (ABG) analysis is the best measure for determining the need for oxygen therapy & for evaluating its effect. Nose & sinuses

Oxygen Induced Ventilation

Assess for oxygen-induced hypo-ventilation in the patient whose main respiratory drive is hypoxia (hypoxic drive), (chronic lung disease who also has carbon dioxide retention (hypercarbia). Arterial carbon dioxide (Paco2)- increased over time. Central chemoreceptors in the brain (medulla) are normally sensitive to increased Paco2 levels. When these receptors are active, they stimulate breathing & increase respiratory rate. When the Paco2 increases gradually to above 60 to 65 mmHg, this normal mechanism to trigger breathing no longer functions. The central chemoreceptors lose sensitivity to increased levels of Paco2 & don't response by increasing the rate & depth of respiration. The loss of sensitivity to high levels of Paco2 is called CO2 narcosis.

The client who is concerned about getting a tracheostomy says, "I will be ugly, with a hole in my neck." What is the nurse's best response? A. "But you know you need this to breathe, right?" B. Do you have a pretty scarf or a large loose collar that you could place over it?" C. "Your family and friends probably won't even care." D. "It won't take you long to learn to manage."

B. "Do you have a pretty scarf or a large loose collar that you could place over it?" Suggesting strategies to cover the tracheostomy recognizes client concerns and explores options for dealing with the effects of the procedure.

The client is admitted to the hospital for COPD, and the physician requests a nasal cannula at 2 L/min. Within 30 minutes, the client's color improves. What does the nurse continue to monitor that may require immediate attention? A. Increasing carbon dioxide levels B. Decreasing respiratory rate C. Increasing adventitious breath sounds D. Increased coughing

B. Decreasing respiratory rate Respiratory rate and depth should be monitored closely while the client receives oxygen, because hypoventilation is seen during the first 30 minutes of oxygen therapy in clients with hypoxic drive for respiration. The client's color will improve (from ashen or gray to pink) because of an increase in PaO2 level before apnea or respiratory arrest occurs from loss of the hypoxic drive.

A new graduate RN discovers that her client, who had a tracheostomy placed the previous day, has completely dislodged both the obturator and the tracheostomy tube. Which action should the nurse take first? A. Auscultate the client's breath sounds while applying a nasal cannula B. Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask C. Apply a 100% non-rebreather mask while administering high-flow oxygen D. Replace the obturator while inserting the tracheostomy tube

B. Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask Because a fresh tracheostomy stoma will collapse, the client will lose his airway patency, which will require the nurse to ventilate the client through the mouth and nose while waiting for assistance to re-cannulate the client. Directing someone else to call the Rapid Response Team allows the nurse to provide immediate care required by the client.

An older adult client is being discharged home with a tracheostomy. Which nursing action is an acceptable assignment for an experienced LPN/LVN? A. Complete the referral form for a home health agency B. Suction the tracheostomy using sterile technique C. Teach the client and spouse about tracheostomy D. Consult with the physician about using a fenestrated tube

B. Suction the tracheostomy using sterile technique Complex sterile procedures are within the education, scope, and practice of the experienced LPN/LVN.

An older adult patient sustained a stroke several weeks ago & is having difficulty swallowing. To prevent aspiration during mealtimes, what does the nurse do? a. Hyper-extend the head to allow food to enter the stomach & not the lungs b. Give thin liquids after each bite of food to help "wash the food down" c. Encourage "dry swallowing" after each bite to clear residue from the throat d. Maintain a low Fowler's position during eating and for 2 hours afterwards

C

The nurse is providing discharge instructions for a patient who much perform self-care of a tracheostomy. The patient has been cheerful & cooperative during the hospital stay & has demonstrated interest & capability in performing self-care. But now the patient begins crying & refuses to leave the hospital. What is the nurse's best response? a. "You have done so well with your self-care. i am sure that you will be okay/" b. "Let me call your family. They can help you to get home & get settled." c. "You have been brave & cheerful, but there is something that is worrying you." d. "We'll delay this teaching until later. Let's choose a scarf for you to wear home."

C

When a patient is requiring oxygen therapy. what is important for the nurse to know? a. Patients require 1 to 10 L/min by nasal cannula in order for oxygen to be effective. b. Oxygen induced hypoventilation is the priority when the PaCO2 levels are unknown. c. Why the patient is receiving oxygen, expected outcomes, & complications. d. The goal is the highest Fio2 possible for the particular device being used.

C

A client has just arrived in the PACU following a successful tracheostomy procedure. Which nursing action must be taken first? A. Suction as needed B. Clean the tracheostomy inner cannula and stoma C. Listen to lung sounds D. Change the tracheostomy dressing as needed

C. Listen to lung sounds Assessment is the first phase of the nursing process. All other actions and procedures are driven by assessment findings. The first nursing action for a client following an airway procedure is to assess the client's respiratory status; this requires auscultation of the lungs.

The client with respiratory failure has been intubated and placed on a ventilator and is requiring 100% oxygen delivery to maintain adequate oxygenation. Twenty-four hours later, the nurse notes new-onset crackles and decreased breath sounds, and the most recent ABGs show a PaO2 level of 95 mm Hg. The ventilator is not set to provide positive end-expiratory pressure (PEEP). Why is the nurse concerned? A. The low PaO2 level may result in oxygen toxicity B. The 100% oxygen delivery requirement indicates immediate extubation C. Lung sounds may indicate absorption atelectasis D. The level of oxygen delivery may indicate absorption atelectasis

C. Lung sounds may indicate absorption atelectasis High levels of oxygen delivery can result in collapsed alveoli and absorption atelectasis. PEEP can help alveoli remain properly inflated.

Which value indicates clinical hypoxemia and the need to increase oxygen delivery? A. Hemoglobin of 22 g/dL B. PaCO2 of 30 mm Hg C. PaO2 of 65 mm Hg D. Oxygen saturation of 88%

C. PaO2 of 65 mm Hg PaO2 of 65 mm Hg indicates low levels of oxygen in the arterial blood; this is termed hypoxemia.

The older adult client with degenerative arthritis is admitted for tracheostomy surgery. What is the best communication method for this client during the postoperative period? A. Computer keyboard B. Magic slate C. Picture board D. Pen and paper

C. Picture board A picture board does not require very much dexterity for communication. Dexterity can be limited to the extent the client finds comfortable.

Oxygen Therapy

Check physician's prescription. Obtain prescription for humidification if oxygen is being delivered at 4 L/min or more. Check skin, ears, back of neck & face every 4 to 8 hours for pressure points & signs of irritation. Purpose- relieves hypoxemia Goal- Use lowest fraction of inspired oxygen for acceptable blood oxygen level without causing harmful side effects.

A patient has a cuffed tracheostomy tube without a pressure relief valve. To prevent tissue damage of the tracheal mucosa, what does the nurse do? a. Deflate the cuff every 2 to 4 hours and maintain as needed. b. Change the tracheostomy tube every 3 days or per hospital policy. c. Assess & record cuff pressures each shift using the occlusive technique d. Assess & record cuff pressures each shift using the minimal leak technique.

D

A client who smokes is being discharged home on oxygen. The client states, "My lungs are already damaged, so I'm not going to quit smoking." What is the discharge nurse's best response? A. "You can quit when you are ready." B. "It's never too late to quit." C. "Just turn off your oxygen when you smoke." D. "You are right, the damage has been done. But let's talk about why smoking around oxygen is dangerous."

D. "You are right, the damage has been done. But let's talk about why smoking around oxygen is dangerous." This is a great opening for the nurse to educate the client about the dangers of smoking in the presence of oxygen, as well as the benefits of quitting.

Respirations of the sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures. The ventilator tube is clear. What is the best immediate action by the nurse? A. Humidifying the oxygen source B. Increasing oxygenation C. Removing the inner cannula of the tracheostomy D. Suctioning the client

D. Suctioning the client Suctioning the client will likely result in clear lung sounds and lower peak pressure, and the appearance of the sputum will indicate whether bleeding is a concern.

A client with a tracheostomy is at increased risk for aspiration. Which nursing intervention(s) will reduce this risk? SELECT ALL THAT APPLY. A. Encourage frequent sipping from a cup B. Encourage water with meals C. Inflate the tracheostomy cuff during meals D. Maintain the client upright for 30 minutes after eating E. Provide small, frequent meals F. Teach the client to "tuck" the chin down in the forward position to swallow

D. Maintain the client upright for 30 minutes after eating At least 30 minutes is required for thinner liquids in the stomach to be thickened in combination with stomach contents and/or removed from the stomach; this reduces the chance of aspiration. E. Provide small, frequent meals. Eating requires significant time and energy. When the client becomes tired, he is more likely to aspirate. Shorter and more frequent intervals of eating tire the client less and reduce the chance of aspiration. F. Teach the client to "tuck" the chin down in the forward position to swallow Tucking the chin downward helps to open the upper esophageal sphincter.

The client with a new tracheostomy has a soiled dressing. What is the best nursing intervention? A. Cut sterile 4 x 4 gauze to fit around the tracheostomy tube B. Reinforce the dressing with sterile 4 x 4 gauze C. Replace the dressing with clean, folded 4 x 4 gauze D. Replace the dressing with sterile, folded 4 x 4 gauze

D. Replace the dressing with sterile, folded 4 x 4 gauze

Simple Facemask

Delivers O2 up to 40% - 60% Minimum of 5 L/min. Mask fits securely over nose & mouth Monitor closely for risk of aspiration.

A client who has experienced a panic attack is being transferred to the medical-surgical ward. The transfer nurse reports that the client is doing much better after receiving bronchodilators via nebulizer and a small dose of oral Valium 4 hours ago in the emergency department. Vital signs are stable with oxygen delivered at 4 L/min via simple facemask. Why is this client at high risk for subsequent respiratory distress? A. The client is not being treated for asthma B. The client has a mental disorder C. The client received a dose of Valium D. The client is receiving oxygen at 4 L/min

D. The client is receiving oxygen at 4 L/min A simple facemask must receive oxygen at a rate of at least 5 L/min to prevent inhalation of exhaled breath, which has low levels of oxygen and can eventually suffocate the client.

Low-Flow Oxygen Delivery Systems

Does not provide enough flow to meet total oxygen & air volume. Nasal cannula (1-6 L) Facemask: Simple, Partial rebreather, non-rebreather. Flow rates greater than 6 L/min don't increase oxygenation because the anatomic dead space (spaces where airflows but the structures are too thick for gas exchange) is full. *Often used for chronic lung disease & for any patient needing long-term oxygen therapy.

Clinical Manifestations of Respiratory Distress

Dyspnea Nasal Flaring Use of accessory muscles to breathe Pursed-lip or diaphragmatic breathing Decreased endurance Skin, mucous membrane changes (pallor, cyanosis)

CRITICAL RESCUE

Ensure that the valve & flaps on a non-rebreather mask are intact & functional during each breath. If the oxygen source should fail or be depleted when both flaps are in place, the patient would be able to inhale room air.

Why do we need oxygen?

Essential for life & function of cells/tissues Respiratory, cardiovascular, hematologic systems work together, providing sufficient tissue perfusion to the body. Oxygen therapy improves oxygenation and tissue perfusion Oxygen is a gas used as a drug for relief of hypoxemia (low levels of oxygen in the blood) & hypoxia (decreased tissue oxygenation) Non-respiratory conditions, such as HF, sepsis, fever, some poisons, & decreased hemoglobin levels or poor hemoglobin quality, can affect oxygenation.

Nasal Cannula

Flow rates of 1-6 L/min. O2 concentrations of 24%-44% (1-6 L/min) Assess patency of nostrils. Assess for changes in respiratory rate & depth

Transtracheal Oxygen Therapy

Flow rates prescribed for rest, activity. TTO- long term method of delivering oxygen directly into the lungs. Most patients using this delivery method have a 55% reduction in required oxygen flow at rest & a 30% decrease with activity. -Small flexible catheter is passed into trachea through small incision -Avoids irritation that nasal prongs cause; is more comfortable.

Cuffed Tube

Has a cuff that seals airway when inflated

Single-lumen tube

Has no inner cannula & is used for patients with long or extra thick necks

Double-lumen tube

Has three parts- outer cannula, inner cannula, & obturator

High-Flow Oxygen Delivery System

High-flow can deliver 24%-100% at 8-15 L/min. Venturi mask, Face tent, aerosol mask, tracheostomy collar, & T-piece. Venturi mask- Adaptor located between bottom of mask & O2 sources. Delivers precise O2 concentration- best source for chronic lung disease. Switch to nasal cannula during mealtimes. T-piece- delivers desired FIO2 for tracheostomy, laryngectomy, ET tubes; Ensures humidifier creates enough mist; Mist should be seen during inspiration & expiration

ACTION ALERT

Monitor the patient receiving high levels of oxygen closely for indications of absorption atelectasis every 1-2 hours when oxygen therapy is started & as often as needed thereafter.

Non-Invasive Postive Pressure Ventilation

NPPV- a technique using positive pressure to keep alveoli open & improve gas exchange without the need for airway intubation. -Used to manage dyspnea, hypercarbia, & acute exacerbations of COPD, cardiogenic pulmonary edema, & acute asthma attacks. -Most common modes: (1) CPAP- which delivers a set positive airway pressure throughout each cycle of inhalation & exhalation; (2) volume-limited or flow-limited, which delivers a set tidal volume with the patients inspiratory effort; (3) pressure-limited, which includes pressure support, pressure control, & bi-level positive airway pressure (BiPAP), which cycles different pressures at inspiration & at expiration

Operative Procedures

Neck is extended & an endotracheal (ET) tube is placed by the anesthesia provider to maintain the airway. Incision then made through the anterior skin of the neck, exposing the tracheal rings, & moving other tissues out of the surgical path. 2nd incision is made through the tracheal rings to enter the trachea.

Tracheostomy

Surgical incision into the trachea to create an airway. -Tracheostomy- the (trachea) stoma, or opening that results from the tracheotomy. -Indications: acute airway obstruction, the need for airway protection, laryngeal trauma, & airway involvement during head or neck surgery. -May be temporary or permanent.

______________ is the result of constant pressure exerted by a tracheostomy cuff causing tracheal dilation & erosion of cartilage.

Tracheomalacia

A patient requires home oxygen therapy. When the home health nurse enters the patient's home for the initial visit, he observes several issues that are safety hazards related to the patient's oxygen therapy. What hazards do these include? (Select all that apply) a. Bottle of wine in the kitchen area b. Package of cigarettes on the coffee table. c. Several decorative candles on the mantel piece d. Grounded outlet with a greet dot on the plate e. Electric fan with a frayed cord in the bathroom f. Computer with a three-pronged plug

b c e

Complications

Tube Obstruction: Occurs as a result of secretions or by cuff displacement. Indicators: difficulty breathing; noisy respirations; difficulty inserting a suction catheter; thick, dry secretions & unexplained peak pressures (if a mechanical ventilator). Tube dislodgment & accidental decannulation: occurs when the tube system is not secure. In the first 72 hours after surgery is an emergency because the tracheostomy tract has not matured & replacement is difficult. The tube may end up in the subcutaneous tissue instead of the trachea. If decannulation occurs after 72 hours extend the patient's neck & open the tissues of the stoma with a curved kelly clamp to secure the airway. -Pneumothorax (air in the chest cavity) can develop during the tracheotomy procedure if the chest cavity is entered- At the apex of the lung- Chest x-rays after placement are used to assess pneumothorax. -Subcutaneous emphysema- when there's an opening or tear in the trachea & air escapes into fresh tissue planes of the neck. -Inspect & palpate for air under the skin around the new tracheostomy (if so notify physician immediately) -Bleeding- small amounts can be expected; but constant oozing- abnormal -Infection- In hospital, use sterile technique to prevent infection Tracheomalacia- constant pressure exerted by the cuff causes tracheal dilation & erosion of cartilage. Manifestations: Increased amount of air is required in the cuff to maintain the seal; a larger trach. tube is required to prevent an air leak @ the stoma; food particles are seen in tracheal secretions; patient doesn't receive the set tidal volume on the ventilator. Management: No special management needed unless bleeding occurs. Prevention: Use an uncuffed tube ASAP; Monitor cuff pressure & air volumes closely & detect changes -Narrowed tracheal lumen is due to scar formation from irritation of tracheal mucosa by the cuff. Manifestation: stenosis is usually seen after the cuff is deflated or the tracheostomy tube is removed. The patient has increased coughing, inability to expectorate secretions or difficulty in breathing or talking. Management: Tracheal dilation or surgical intervention is used. Prevention: prevent pulling of & traction on the trach. tube; properly secure the tube in the midline position; maintain proper cuff pressure; minimize oronasal intubation time. Tracheoesophageal Fistula: Excessive cuff pressure causes erosion of the posterior wall of the trachea. A hole is created between the trachea & the anterior esophagus. The patient at highest risk also has a nasogastric tube present. Manifestations: Similar to tracheomalcia: Food particles are seen in tracheal secretions; Increased air in cuff is needed to achieve a seal; patient has increased coughing & choking while eating; patient does not receive the set tidal volume on the ventilator. Management: Manually administer oxygen by mask to prevent hypoxemia. Use a small, soft feeding tube instead of a nasogastric tube for tube feedings. Monitor the patient with a nasogastric tube closely; assess for TEF & aspiration. Prevention: Maintain cuff pressure. Monitor the amount of air needed for inflation & detect changes; progress to a deflated cuff or cuffless tube ASAP. Trachea-INNOMINATE Artery Fistula: A malpositioned tube causes its distal tip to push against the lateral wall of the tracheostomy. Continued pressure causes necrosis & erosion of the innominate artery. THIS IS A MEDICAL EMERGENCY. Manifestations: the trach. tube pulsates to synchrony with the heart beat. There's heavy bleeding from the stoma. Life-threatening complication. Management: Remove the trach. tube immediately. Apply direct pressure to the innominate artery at the stoma site; prepare the patient for immediate repair surgery. Prevention: Correct the tube size, length & midline position. Prevent pulling or tugging on the trach. tube

Oxygen Delivery Systems

Type used depends on : Oxygen concentration required/achieved; importance of accuracy & control of oxygen concentration; patient comfort; importance of humidity; patient mobility.

Cuffless tube

Used for long-term management of patients not on mechanical ventilation or at high risk for aspiration

Metal tracheostomy tube

Used for permanent tracheostomy

Cuffed fenestrated tube

Used often with patients with spinal cord paralysis or muscular disease who don't require ventilator all the time

Fenestrated tube

Used when weaning a patient from a ventilator; allows the patient to speak

Talking tacheostomy tube

Used with patients who can speak while on a ventilator for a long-term basis

A patient with a tracheostomy or endotracheal tube has inline sunctioning. Which nursing interventions apply to proper suctioning technique? (Select all that apply) a. Oxygenate the patient before suctioning. b. Instruct the patient that he or she is going to be suctioned. c. Suctioning time is the same for a tracheostomy and an endotracheal tube. d. The suction line is unlocked after suctioning is completed. e. The suction tubing is locked after suctioning is completed.

a b c e

A patient has a recent tracheostomy. What necessary equipment does the nurse ensure is kept at the bedside? (Select all that apply) a. Ambu bag b. Pair of wire cutters c. Oxygen tubing d. Suction equipment e. Tracheostomy tube with obturator

a c d e

What are possible complications that can occur with suctioning from an artificial airway? (Select all that apply) a. Infection b. coughing c. Hypoxia d. Tissue (mucosa) trauma e. Vagal stimulation f. Bronchospasm g. Cardiac dysrhythmias

a c d e f g

An older adult client is at risk for aspirating food or fluids. Which are the most appropriate nursing actions to prevent this problem? (Select all that apply) a. Provide close supervision if the patient is self-feeding. b. Instruct the patient to tilt the head back when swallowing c. Obtain an order for a clear liquid diet and offer small but frequent amounts. d. instruct the patient to tuck the chin down when swallowing e. place the patient in an upright position

a d e

Which statement by the nursing student indicates an understanding of the deflation of the tracheostomy cuff? a. "The cuff is deflated to allow the patient to speak." b. "The cuff is deflated to permit suctioning more easily." c. "The cuff should never be deflated because the patient will choke." d. "The cuff should be deflated to facilitate access for tracheostomy care."

a. "The cuff is deflated to allow the patient to speak."

The nursing diagnosis for the patient receiving oxygen therapy is risk for impaired skin integrity. Which nursing interventions are related to prevention of skin breakdown? (Select all that apply) a. Assess the patient's ears, back of neck, and face at least every 4 to 8 hours for irritation b. Apply padding on tubing to prevent pressure on skin c. Use petroleum jelly on nostrils, face, and lips to relieve dryness d. Assess nasal and mucous membranes for dryness and cracks e. Obtain an order for humidification when oxygen is being delivered at 6 L/min or more f. Provide mouth care every 8 hours and as needed g. Position tubing so it will not pull on patient's ears

a. Assess the patient's ears, back of neck, and face at least every 4 to 8 hours for irritation b. Apply padding on tubing to prevent pressure on skin d. Assess nasal and mucous membranes for dryness and cracks e. Obtain an order for humidification when oxygen is being delivered at 6 L/min or more f. Provide mouth care every 8 hours and as needed g. Position tubing so it will not pull on patient's ears

Increased risk for oxygen toxicity is related to which factors? (Select all that apply) a. Continuous delivery of oxygen at greater than 50% concentration b. Delivery of high concentration of oxygen over 24 to 48 hours c. The severity and extent of lung disease d. Neglecting to monitor the patient's status and reducing oxygen concentration as soon as possible e. Excluding measures such as continuous positive airway pressure (CPAP) or positive end-expiratory pressure (PEEP)

a. Continuous delivery of oxygen at greater than 50% concentration b. Delivery of high concentration of oxygen over 24 to 48 hours c. The severity and extent of lung disease d. Neglecting to monitor the patient's status and reducing oxygen concentration as soon as possible e. Excluding measures such as continuous positive airway pressure (CPAP) or positive end-expiratory pressure (PEEP)

The physician orders transtracheal oxygen therapy for the patient with respiratory difficulty. What does the nurse tell the patient's family is the purpose of this type oxygen deliver system? a. Delivers oxygen directly into the lungs b. Keeps the small air sacs open to improve gas exchange c. Prevents the need for an endotracheal tube d. Provides high humidity with oxygen delivery

a. Delivers oxygen directly into the lungs

The patient required emergency intubation and currently has an artificial airway in place. Oxygen is being administered directly from the wall source. Why would warmed and humidified oxygen be a more appropriate choice for this patient? a. Helps prevent tracheal damage b. Promotes thick secretions c. Is more comfortable for the patient d. Is less likely to cause oxygen toxicity

a. Helps prevent tracheal damage

Which factors are considered hazards associated with oxygen therapy? (Select all that apply) a. Increased combustion b. Oxygen narcosis c. Oxygen toxicity d. Absorption atelectasis e. Hypoxic drive f. Oxygen-induced hypoventilation

a. Increased combustion c. Oxygen toxicity d. Absorption atelectasis f. Oxygen-induced hypoventilation

The patient is receiving preoperative teaching for a partial laryngectomy and will have a tracheostomy postoperatively. How does the nurse define a tracheostomy to the patient? a. Opening in the trachea that enables breathing b. Temporary procedure that will be reversed at a later date c. Technique using positive pressure to improve gas exchange d. Procedure that holds open the upper airways

a. Opening in the trachea that enables breathing

The patient has a temporary tracheostomy following surgery to the neck area to remove a benign tumor. Which nursing intervention is performed to prevent obstruction f the tracheostomy tube? a. Provide tracheal suctioning when there are noisy respirations b. Provide oxygenation to maintain pulse oximeter readings c. Inflate the cuff to maximum pressure and check it once per shift. d. Suction regularly and PRN with a Yankauer suction

a. Provide tracheal suctioning when there are noisy respirations

The nurse is caring for a patient with a tracheostomy who has recently been transferred from the ICU, but he has had no unusual occurrences related to the tracheostomy or his oxygenation status. What does the routine care for this patient include? a. Thorough respiratory assessment at least every 2 hours b. Maintain the cuff pressure between 50 and 100 mm Hg c. Suctioning as needed; maximum suction time of 20 seconds d. Changing the tracheostomy dressing once a day

a. Thorough respiratory assessment at least every 2 hours

Before completeing the morning assessment, the nurse concludes that a patient is experiencing inadequate oxygenation & tissue perfusion as a result of respiratory problems. Which assessment findings support the nurse's conclusion? (Select all that apply) a. Inspiratory & expiraotyr effort is shallow, even, & quiet. b. Patient must take a breath after every third or fourth word c. Skin is pale, pink, & dry. d. Patient appears strained and fatigued. e. Pulse of 95 beats/min, respiratory rate of 30/min. f. patient does not want to eat.

b d e

A patient with a tracheostomy tube is able to speak & is no longer on mechanical ventilation. Which type of tracheostomy tube does this patient have? (Select all that apply) a. Cuffless tube b. Fenestrated tube with inner cannula removed & the red stopper locked in place c. Standard inflated cuffed tube d. Size #6 Shiley inflated cuffed with a Passy-Muir valve. e. Size #6 Shiley deflated cuffed that is capped.

b e

The patient has an endotracheal tube and requires frequent suctioning for copious secretions. What is a complication of tracheal suctioning? a. Atelectasis b. Hypoxia c. Hypercarbia d. Bronchodilation

b. Hypoxia

The patient is receiving oxygen therapy for respiratory problems. According to NIC interventions for administration and monitoring of its effectiveness, what does the nurse do? a. Monitor the effectiveness of oxygen therapy at least once every 8 hours b. Monitor for signs of oxygen toxicity and absorption atelectasis c. Instruct the patient to replace the oxygen mask when the device is removed d. Ask the respiratory therapist to monitor the oxygen flow and patient response

b. Monitor for signs of oxygen toxicity and absorption atelectasis

The patient sustained a serious crush injury to the neck and had a tracheostomy tube placed yesterday. As the nurse is performing tracheostomy care, the patient suddenly sneezes very forcefully and the tracheostomy tube falls out onto the bed linens. What does the nurse do? a. Ventilate the patient with 100% oxygen and notify the physician b. Quickly and gently replace the tube with a clean cannula kept at the bedside c. Quickly rinse the tube with sterile solution and gently replace it d. Give the patient oxygen; call for assistance and a new tracheostomy kit.

b. Quickly and gently replace the tube with a clean cannula kept at the bedside

The nurse is suctioning the secretions from a patient's endotracheal tube. The patient demonstrates a vagal response by a drop in heart rate to 54 and a drop in BP to 90/50. After stopping suctioning, what is the nurse's priority action? a. Allow the patient to rest for at least 10 mins. b. Monitor the patient & call the Rapid Response Team. c. Oxygenate with 100% oxygen & monitor the patient d. Administer atropine according to standing orders

c

Which clinical finding in a patient with a recent tracheostomy is the most serious & requires immediate intervention? a. Increased cough & difficulty expectorating secretions b. Food particles in the tracheal secretions c. Pulsating tracheostomy tube in synchrony with the heart beat. d. Set tidal volume on the ventilator not being received by the patient.

c

The patient is being discharged and requires home oxygen therapy with a reservoir-type nasal cannula. He asks the nurse, "Why can't I just take this nasal cannula that I have been using in the hospital?" What is the nurse's best response? a. "The doctor ordered the cannula, so your insurance company should cover the cost." b. "With the used cannula there is a risk of a hospital-acquired infection." c. "This special nasal cannula allows you to decrease the oxygen flow by 50%." d. "This nasal cannula is much better. It is more flexible and comfortable to wear.

c. "This special nasal cannula allows you to decrease the oxygen flow by 50%."

The patient is receiving warmed and humidified oxygen. The respiratory therapist informs the nurse that several other patients on other units have developed hospital-acquired infections and Pseudomonas aeruginosa has been identified as the organism. What does the nurse do? a. Place the patient in respiratory isolation b. Obtain an order for a sputum culture c. Change the humidifier every 24 hours d. Obtain an order to discontinue the humidifier

c. Change the humidifier every 24 hours

Nursing interventions to prevent infection in patients with humidified oxygen include which actions? a. Use sterile normal saline to provide moisture b. Drain condensation into the humidifier c. Drain condensation from the water trap d. Maintain a sterile closed system at all times

c. Drain condensation from the water trap

The patient is receiving oxygen therapy through a non-rebreather mask. What is the correct nursing intervention? a. Maintain liter flow so tat the reservoir bag is up to one-half full b. Maintain 60% to 75% FiO2 at 6 to 11 L/min c. Ensure that valves and rubber flaps are patent, functional, and not stuck d. Assess for effectiveness and switch to partial rebreather for more precise FiO2.

c. Ensure that valves and rubber flaps are patent, functional, and not stuck

The patient returns from the operating room and the nurse assess for subcutaneous emphysema which is a potential complication associated with tracheostomy. How does the nurse assess for this complication? a. Checking the volume of the pilot balloon b. Listening for airflow through the tube c. Inspecting and palpating for air under the skin d. Assessing the tube for patency

c. Inspecting and palpating for air under the skin

The patient with chronic obstructive pulmonary disease (COPD) is admitted to the hospital with oxygen-induced hypoventilation. What is the respiratory stimulus t breathe for this patient? a. High carbon dioxide (60 to 65 mm Hg) level in the blood that rose over time b. Low level of carbon dioxide concentration in the blood, as sensed by the chemoreceptors in the brain c. Low level of oxygen concentration in the blood, as sensed by the peripheral chemoreceptors d. Oxygen narcosis which stimulates central chemoreceptors in the brain

c. Low level of carbon dioxide concentration in the blood, as sensed by the chemoreceptors in the brain

The nurse is administering oxygen to the patient who is hypoxic and has chronic high levels of carbon dioxide. Which oxygen therapy prevents a respiratory complication for this patient? a. FiO2 higher than the usual 2 to 4 L/min per nasal cannula b. Venturi mask of 40% for the delivery of oxygen c. Lower concentration of oxygen (1 to 2 L/min) per nasal cannula d. Variable Fio2 via partial rebreather mask

c. Lower concentration of oxygen (1 to 2 L/min) per nasal cannula

The patient is receiving a high concentration of oxygen as a temporary emergency measure. Which nursing action is the most appropriate to prevent complications associated with high flow oxygen? a. Auscultate the lungs every 4 hours for oxygen toxicity. b. Increase the oxygen if the PaO2 level is less than 93 mm Hg. c. Monitor the prescribed oxygen level and length of therapy d. Decrease the oxygen if the patient's condition des not respond

c. Monitor the prescribed oxygen level and length of therapy

The patient with a face mask at 5 L/min is able to eat. Which nursing intervention is performed at mealtimes? a. Change the mask to a nasal cannula of 6 L/min or more b. Have the patient work around the face mask as best as possible c. Obtain a physician order for a nasal cannula at 5 L/min d. Obtain a physician order to remove the mask at meals

c. Obtain a physician order for a nasal cannula at 5 L/min

The patient returns from the operating room after having a tracheostomy. While assessing the patient, which observations made by the nurse warrant immediate notification of the physician? a. Patient is alert but unable to speak and has difficulty communicating his needs. b. Small amount of bleeding present at the incision c. Skin is puffy at the neck area with a crackling sensation d. Respirations are audible and noisy with an increased respiratory rate.

c. Skin is puffy at the neck area with a crackling sensation

The patient was intubated for acute respiratory failure, and there is an endotracheal tube in place. Which nursing intervention is not appropriate for this patient? a. Ensure that the oxygen is warm and humidified b. Suction the airway, then the mouth, and give oral care c. Suction the airway with the oral suction equipment d. Position the tubing so it does not pull on the airway.

c. Suction the airway with the oral suction equipment

The patient with an oxygen delivery device would like to ambulate to the bathroom but the tubing is too short. Extension tubing is added. What is the maximum length of the tubing that can be added in order to deliver the amount of oxygen needed for that device? a. 25 feet b. 35 feet c. 45 feet d. 50 feet

d. 50 feet

What is the best description of the nurse's role in the deliver of oxygen therapy? a. Receiving the therapy report from the respiratory therapist b. Evaluating the response to oxygen therapy c. Contacting respiratory therapy for the devices d. Being familiar with the devices and techniques used in order to provide proper care

d. Being familiar with the devices and techniques used in order to provide proper care

The patient is at high risk or unknown risk for oxygen-induced hypoventilation. What must the nurse monitor for? a. Signs of nonproductive cough, chest pain, crackles, and hypoxemia b. Change of skin tone from pink to gray color after several minutes of oxygen therapy c. Signs and symptoms of hypoventilation rather than hypoxemia d. Changes in level of consciousness, apnea, and respiratory pattern

d. Changes in level of consciousness, apnea, and respiratory pattern

While the nursing student changes the patient's tracheostomy dressing, the nurse observes the student using a pair of scissors to cut a 4 X 4 gauze pad to make a split dressing that will fit around the tracheostomy tube. What is the nurse's best action? a. Give the student positive reinforcement for use of materials and technique b. Report the student to the instructor for remediation of the skill c. Change the dressing immediately after the student has left the room d. Direct the student in the correct use of materials and explain the rationale

d. Direct the student in the correct use of materials and explain the rationale

The patient with a tracheostomy is being discharged to home. In patient teaching, what does the nurse instruct the patient to do? a. Use sterile technique when suctioning b. Instill tap water into the artificial airway c. Clean the tracheostomy tube with soap and water d. Increase the humidity in the home

d. Increase the humidity in the home

The patient with a permanent tracheostomy is interested in developing an exercise regimen. Which activity does the nurse advise the patient to avoid? a. Aerobics b. Tennis c. Golf d. Swimming

d. Swimming

The patient with a tracheostomy develops increased coughing, inability to expectorate secretions, and difficulty breathing. What are these assessment findings related to? a. Over inflation of the pilot balloon b. Tracheoesophageal fistula c. Cuff leak and rupture d. Tracheal stenosis

d. Tracheal stenosis

The patient with an endotracheal tube in place has dry mucous membranes and lips related to the tube and the partial open mouth position. What techniques does the nurse use to provide this patient with frequent oral care? a. Cleanses the mouth with glycerin swabs b. Provides alcohol-based mouth rinse and oral suction c. Cleanses with a mixture of hydrogen peroxide and water d. Uses toothettes or a soft-bristled brush moistened in water

d. Uses toothettes or a soft-bristled brush moistened in water