Ch.28 EAQ
A patient is being admitted with severe respiratory distress and will require an Fio 2 greater than 80%. Prior to possible intubation and mechanical ventilation, the nurse anticipates using which oxygen delivery equipment? Facemask Venturi mask Non-rebreather mask Partial rebreather mask
Ans: C Non-rebreather mask Rationale: Non-rebreather masks allow the highest oxygen level of the low-flow systems and are often used for patients whose respiratory status is unstable and who may require intubation. The facemask and the partial rebreather mask are used for patients who are more stable. The Venturi mask is used for patients with chronic lung disease to allow for precise oxygen delivery.
After surgical placement of a tracheostomy tube, what is the recommended method to verify placement? Chest x-ray Bronchoscopy Symmetrical chest expansion Auscultation of bilateral lung sounds
Ans: A Chest xray Rationale: Chest x-ray is the recommended standard to verify placement. Noting asymmetry of lung sounds and chest expansion gives valuable information but is not definitive for tracheostomy placement. A bronchoscopy is not used to verify placement of a tracheostomy tube.
A patient requiring prolonged mechanical ventilation after laryngeal trauma is scheduled for tracheostomy surgery. What does the nurse include when teaching this patient about the reason for this surgery? "This may make it possible to stop using the ventilator." "The tracheostomy will help the trauma site to heal faster." "The tracheostomy will help prevent respiratory infection." "You will be able to talk and eat once you have a tracheostomy."
Ans: A "This may make it possible to stop using the ventilator." Rationale: A tracheostomy placed for patients with laryngeal trauma will essentially bypass the damaged airway and improve the patient's ability to breathe without mechanical ventilation. It does not help the trauma site to heal faster or prevent respiratory infection. Patients with a tracheostomy will eventually be able to eat and speak, but not immediately.
A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen with a Venturi mask at a rate of 3 L/min. Prior to initiating oxygen therapy, the patient appeared anxious with gray skin, a respiratory rate of 24 breaths/min, and an oxygen saturation of 87%. After 15 minutes of oxygen therapy, the nurse observes the patient resting with closed eyes, pink coloration, a respiratory rate of 12 breaths/min, and an oxygen saturation of 95%. Which action by the nurse is correct? Decrease the oxygen to 2 L/min to improve respiratory rate. Increase the oxygen to 4 L/min to improve oxygen saturation. Request an order for arterial blood gases to evaluate for hypercarbia. Change the Venturi mask to a nasal cannula to further reduce anxiety
Ans: A Decrease the oxygen to 2 L/min to improve respiratory rate. Rationale: Patients with chronic hypercarbia are at risk for oxygen-induced hypoventilation. Patients with COPD are more likely to have chronic hypercarbia. This patient has a slowed respiratory rate and an altered level of consciousness indicating hypoventilation, which can occur within the first 30 minutes of oxygen therapy. The nurse should reduce the oxygen flow to see if the respiratory rate improves. Although many patients with COPD become anxious with a facemask, this patient is currently not demonstrating signs of anxiety. Increasing the oxygen flow will only increase the risk for hypoventilation. An arterial blood gas will be a part of the ongoing assessment but will not distinguish between acute and chronic hypercarbia.
In a patient with a tracheostomy, the nurse notes that the cuff requires increasing amounts of air in order to maintain the seal and observes food particles in the tracheal secretions. Which tracheal complication does the nurse suspect occurred in this patient? Dilation Infection Stenosis Obstruction
Ans: A Dilation Rationale: Tracheomalacia occurs when the constant pressure from the cuff causes tracheal dilation and erosion of the cartilage. Manifestations of this condition are a need for increasing amounts of air in the tracheal tube cuff, food in tracheal secretions, and failure to receive the full tidal volume delivered by the ventilator. Tracheal infection is characterized by purulent drainage at the stoma site, along with redness, pain, and swelling. Tracheal stenosis involves scar formation caused by tracheal tube pressure and is usually observed after the tracheostomy tube is removed when stridor, difficulty breathing and swallowing, and coughing occur. Tracheal obstruction is characterized by an inability to move air in and out of the lungs.
A patient has just been admitted to the emergency department and requires high-flow oxygen therapy after suffering facial burns and smoke inhalation. Which oxygen delivery device should the nurse use initially? Face tent Venturi mask Nasal cannula Non-rebreather mask
Ans: A Face tent Rationale: A patient with smoke inhalation and facial burns who requires high-flow oxygen should initially be placed on a face tent because this is the only noninvasive high-flow device that will minimize painful and contaminating contact with burned facial tissue. Although a Venturi mask and a non-rebreather mask are high-flow oxygen delivery devices, they require snug fitting on the face, which can be painful and can introduce infection to compromised facial skin. A nasal cannula is not a high-flow device.
Which factor is a manifestation of tracheoesophageal fistula (TEF)? Increased cough and choking while eating Lacking food particles in tracheal secretions Receiving the set tidal volume on the ventilator Decreasing air in the cuff needed to achieve a seal
Ans: A Increased cough and choking while eating Rationale: TEF causes excessive pressure on the cuff that leads to erosion of the posterior wall of the trachea which, in turn, leads to increased coughing and choking while eating. A manifestation of TEF is the presence of food particles in tracheal secretions. With TEF, the patient does not receive the set tidal volume on the ventilator, and increasing air in the cuff is needed in order to achieve a seal.
Which value indicates clinical hypoxemia and the need to increase oxygen delivery? PaO 2 of 65 mm Hg PaCO 2 of 30 mm Hg Hemoglobin of 22 g/dL Oxygen saturation of 88%
Ans: A PaO 2 of 65 mm Hg Rationale: A PaO 2 of 65 mm Hg indicates low levels of oxygen in the arterial blood; this is considered hypoxemia. Hemoglobin measures oxygen-carrying capacity. PaCO 2 of 30 mm Hg indicates low carbon dioxide levels in the blood. Oxygen saturation measures tissue perfusion.
A patient with a tracheostomy is receiving feedings via a nasogastric tube, during which the patient experiences increased coughing and choking. The nurse notes that the tracheostomy cuff requires increasing amounts of air to maintain the seal, and when suctioning the tracheostomy, food particles are present in the tracheal secretions. After notifying the provider of these observations, which procedure does the nurse expect to be performed? Placement of a jejunostomy tube Tracheal dilatation in the operating room Insertion of a fenestrated tracheostomy tube Reintubation with a larger tracheostomy tube
Ans: A Placement of a jejunostomy tube Rationale: This patient has signs of a tracheoesophageal fistula, where excessive cuff pressure causes an erosion of the posterior wall of the trachea and into the anterior esophagus. Patients who develop this should either be fed with a very small bore feeding tube or should have surgical placement of a gastrostomy or jejunostomy tube. A fenestrated tracheostomy tube is used to facilitate coughing or speaking. Placing a larger tracheostomy tube will increase pressure on the tracheal wall. The trachea does not need to be dilated.
An older adult patient is being discharged home with a tracheostomy. Which nursing action is an acceptable assignment for an experienced LPN/LVN? Suction the tracheostomy using sterile technique. Complete the referral form for a home health agency. Teach the patient and spouse about tracheostomy care. Consult with the health care provider about using a fenestrated tube.
Ans: A Suction the tracheostomy using sterile technique. Rationale: Complex sterile procedures are within the education and scope of practice of the experienced LPN/LVN. Completion of patient referral forms, patient and family teaching, and consulting with the health care provider are all actions that must be performed by an RN.
When the inner cannula is removed from a fenestrated tracheostomy tube, what is an expected patient function? The patient will be able to speak. The patient is able to swallow small sips of water. Full range of motion of the neck will be restored. The patient will be able to expectorate secretions more effectively.
Ans: A The patient will be able to speak Rationale: A fenestrated tube has holes that allow air to pass during exhalation through the vocal cords, enabling speech. Removing the inner cannula enables this feature. The patient is at risk for aspiration until determined to be safe with a swallow study, so removal of the inner cannula does not mean it is safe to sip water. Removal of the inner cannula does not affect range of motion of the neck nor the patient's ability to cough more effectively.
Which of these are valuable instructions for the nurse regarding best practices for patient safety during oxygen therapy? Select all that apply. "Position the tubing so it does not pull on the patient's face or the artificial airway." "Mouth care should be infrequent to prevent irritation to the nasal cannula." "The presence of smoking, lit matches, or candles in the immediate area is considered safe." "Lubrication of the patient's nostrils, face, and lips is essential to prevent drying." "Ensure that the oxygen and humidification equipment are functioning properly."
Ans: A, D, E "Position the tubing so it does not pull on the patient's face or the artificial airway." "Lubrication of the patient's nostrils, face, and lips is essential to prevent drying.""Ensure that the oxygen and humidification equipment are functioning properly." Rationale: During oxygen therapy, lubrication of the patient's nostrils, face, and lips with nonpetroleum cream is essential to relieve the drying effects of oxygen. For effective oxygen therapy, the oxygen and humidification equipment should be functioning properly. The tubing should be positioned in such a way that it does not pull on the patient's face or artificial airway. Mouth care is an integral part of caring for a patient who is undergoing oxygen therapy and should be provided every 8 hours or as needed. Care should be taken that smoking, lit matches, and candles are not present in the immediate vicinity of the oxygen therapy room or area because oxygen is combustible.
Which principles are important for the nurse to remember about oxygen administration? Select all that apply. Nitrogen helps prevent alveolar collapse, as it doesn't cross over capillary membranes. When a patient experiences air hunger, increase the PaCO 2 to improve the balance. It is important to keep the patient's PaO 2 at greater than 90 mm Hg for optimal outcomes. Oxygen is harmless; it is part of what we breathe normally and toxicity is unlikely. High levels of oxygen dilute the nitrogen in the lungs leading to alveolar collapse.
Ans: A, E Nitrogen helps prevent alveolar collapse, as it doesn't cross over capillary membranes. High levels of oxygen dilute the nitrogen in the lungs leading to alveolar collapse. Rationale: Nitrogen, which is 79% of room air, helps to prevent alveolar collapse because it doesn't cross over the capillary membranes into the blood. High levels of oxygen administration dilute the nitrogen when it diffuses across the membrane into the circulation, and the alveoli collapse, leading to atelectasis. Oxygen administration can cause toxicity and must be monitored closely. An increased PaCO 2 will result when the patient is retaining CO 2; this is not a desirable state. PaO 2 levels of greater than 90 mm Hg should be reported to the health care provider.
The nurse is educating a patient and the caregivers at the time of discharge about home care after a tracheostomy. Which teachings would be beneficial for the patient? Select all that apply. "Perform airway care." "Wear a shower shield." "Wear a medical alert bracelet." "Maintain constant humidity at home." "Avoid covering the opening of the stoma."
Ans: A,B,C "Perform airway care." "Wear a shower shield." "Wear a medical alert bracelet." Rationale: Airway care includes cleaning the stoma regularly, assessing the signs of infection, and using a clean suction technique to prevent infection. A shower shield should be worn over a tracheostomy tube to prevent water from entering the airway. A medical alert bracelet identifies a patient's inability to speak. The patient should maintain increased humidity at home as part of home care. Covering the openings will filter the air entering the stoma, which, in turn, keeps humidity in the airways and enhances the appearance.
Vagal stimulation during suctioning can contribute to which conditions? Select all that apply. Asystole Heart block Bradycardia Hypertension Bronchospasm
Ans: A,B,C Asystole, Heart block, Bradycardia Rationale: Tracheal suctioning can cause a vagal response. This stimulus influences the electrical system of the heart, potentially leading to decreased heart rate (bradycardia), heart block, asystole, or other dysrhythmias. Bronchospasm would not be induced by this type of stimulus. Vagal stimulation can result in hypotension, not hypertension.
What should the nurse include when instructing a patient about safe practice for home-care oxygen therapy? Select all that apply. Safety precautions Maintenance of equipment Equipment needed for home oxygen therapy Nonnecessity of selecting a community health nursing agency Nonnecessity of reevaluating the need for home oxygen therapy
Ans: A,B,C Safety precaution. Maintenance of equipment. Equipment needed for home oxygen therapy Rationale: When a patient is taught about self-management of home-care oxygen therapy, it includes safety precautions and how to maintain the equipment. The nurse should also instruct the patient about the equipment required for home oxygen therapy, which may include the oxygen source, delivery devices, and humidity sources. Reevaluation of the need for home oxygen therapy is required on a periodic basis. It is vital to have a community health nursing agency available for follow-up care in the home.
A patient who needs oxygen therapy wants the cost to be reimbursed by Medicare. What criteria does Medicare use to cover the cost of home oxygen therapy for the patient? Select all that apply. Arterial oxygen saturation of less than 88% on room air Arterial oxygen saturation of less than 88% during exercise Partial pressure of arterial oxygen level of less than 55 mm Hg Partial pressure of arterial oxygen level of less than 55 mm Hg when nonpulmonary problems cause the hypoxemia Arterial oxygen saturation of less than 88% when oxygen is needed only during the night
Ans: A,C Arterial oxygen saturation of less than 88% on room air.Partial pressure of arterial oxygen level of less than 55 mm Hg Rationale: For Medicare to cover the cost of home oxygen therapy, the patient must have severe hypoxemia, defined as a partial pressure of arterial oxygen (PaO 2) level of less than 55 mm Hg or arterial oxygen saturation (SpO 2) of less than 88% on room air and at rest. The criteria may vary when oxygen is needed with exercise or only during the night. It also varies when the hypoxemia is due to nonpulmonary problems.
Which assessment findings may indicate a tracheostomy tube is obstructed? Select all that apply. Dyspnea Bradypnea Noisy respirations Edema around the stoma Asymmetrical chest movement Difficulty inserting a suction catheter
Ans: A,C,F Rationale: Noisy respirations are heard when secretions accumulate and obstruct air flow in the tube. Dyspnea will occur if the airway is obstructed. Dried secretions may make it difficult to pass a suction catheter through the tube. Asymmetry of chest movement does not indicate an obstructed airway. If the tracheostomy is obstructed, tachypnea would result, not bradypnea. Edema around the stoma is external to the tracheostomy tube and would not obstruct the tube.
A patient has a fenestrated tracheostomy tube in place. Which multidisciplinary team would be involved in the discharge planning process, specific to the tracheostomy? Physical therapy Speech therapy Occupational therapy Patient care assistant
Ans: B Speech therapy Rationale: A vital member of the multidisciplinary team for the patient with a fenestrated tracheostomy tube is speech therapy. A speech therapist can teach the patient about swallowing and communication with the tube in place. Physical therapy and occupational therapy may be beneficial to the patient for conditioning and strengthening, but they are not specific to the tracheostomy. The patient may utilize a patient care assistant as well, but this is not specific to the tracheostomy.
Which patient has the most urgent need for frequent nursing assessment? A middle-aged patient who was admitted yesterday with pneumonia and is receiving oxygen at 2 L/min through a nasal cannula An older adult patient who was admitted 2 hours ago with emphysema and dyspnea, has a 45-year two-pack-per-day smoking history, and is receiving 50% oxygen through a Venturi mask A young patient who has had a tracheostomy for 1 week, who is on room air with SpO 2 at percents in the upper 90s, who has been receiving antibiotic therapy for 16 hours, and who has foul-smelling drainage on the tracheostomy ties An older adult patient 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
Ans: B An older adult patient who was admitted 2 hours ago with emphysema and dyspnea, has a 45-year two-pack-per-day smoking history, and is receiving 50% oxygen through a Venturi mask Rationale: The older adult with a long history of smoking and chronic lung disease is at elevated risk for respiratory depression owing to the hypoxic drive of respirations countered by high levels of oxygen; this patient must be assessed frequently while receiving high-flow oxygen. The young patient with no signs or symptoms of respiratory compromise and the patient who meets discharge criteria do not require frequent assessment. Although the middle-aged patient with pneumonia will require more frequent assessment than a patient who does not require oxygen therapy, the older patient on higher-flow oxygen is at greater risk for respiratory demise and therefore needs frequent assessment more urgently.
A patient is admitted to the hospital for chronic obstructive pulmonary disease (COPD), and the health care provider requests oxygen via nasal cannula at 2 L/min. Within 30 minutes, the patient's color improves. What does the nurse continue to monitor that may require immediate attention? Increased coughing Decreasing respiratory rate Increasing carbon dioxide levels Increasing adventitious breath sounds
Ans: B Decreasing RR Rationale: Respiratory rate and depth should be monitored closely while the patient receives oxygen because hypoventilation is seen during the first 30 minutes of oxygen therapy in patients with hypoxic drive for respiration. The patient's color will improve (from ashen or gray to pink) because of an increase in PaO 2 level before apnea or respiratory arrest occurs from loss of the hypoxic drive. The COPD patient is not sensitive to PaCO 2; oxygen administration can cause high PaO 2 levels. Monitoring for adventitious breath sounds is important, but these would not be a result of the oxygen that the patient is receiving. The ability to cough and breathe deeply is a positive sign.
The nurse is assisting a patient with a tracheostomy to eat. Which is an important nursing action to help the patient swallow and avoid aspiration? Offer fluids using a straw and avoid giving thickened fluids. Elevate the head of the bed for at least 30 minutes after eating. Encourage the patient to avoid swallowing between bites of food. Increase the pressure in the tracheostomy cuff to block food particle
Ans: B Elevate the head of the bed for at least 30 minutes after eating. Rationale: The nurse should elevate the head of the bed during eating and for at least 30 minutes after eating to prevent aspiration and reflux. The patient should be encouraged to take "dry swallows" between bites of food to clear the esophagus. Increasing the pressure puts pressure on the esophagus. Patients should take small amounts of fluids from a spoon to facilitate swallowing.
In caring for a patient during the first few days after tracheostomy placement, what nursing action is included in wound care? Applying Steri-Strips to secure the tube Folding standard gauze 4 × 4s to fit around the tube Cutting a slit in standard gauze 4 × 4s for ease of placement around tube Assessing the stoma site every 24 hours for purulent drainage, redness, and swellin
Ans: B Folding standard gauze 4 × 4s to fit around the tube Rationale: It is recommended that intact 4 × 4s be folded and placed around the tube. Cutting the 4 × 4 gauze might release small pieces of gauze that may be aspirated. The stoma site should be assessed every shift. Steri-Strips are not used to stabilize the tube.
A patient 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 arterial blood gases (ABGs) show a PaO 2 level of 95 mm Hg. The ventilator is not set to provide positive end-expiratory pressure (PEEP). Why is the nurse concerned? The low PaO 2 level may result in oxygen toxicity. Lung sounds may indicate absorption atelectasis. The level of oxygen delivery may indicate absorption atelectasis. The 100% oxygen delivery requirement indicates immediate extubation.
Ans: B Lung sounds may indicate absorption atelectasis. Rationale: High levels of oxygen delivery can result in collapsed alveoli and absorption atelectasis. PEEP can help alveoli remain properly inflated. High PaO 2 levels may result in oxygen toxicity. The need for 100% oxygen delivery does not suggest that the patient should be extubated; rather, it suggests that the patient continues to require intubation and mechanical ventilation. Although high levels of oxygen delivery can result in absorption atelectasis, this is not an indicator; rather, it is a cause.
Which principle should guide the nurse's decision regarding oral care for a patient with a tracheostomy during the first 24 hours postoperative? High protein intake is indicated to promote optimal healing. Oral care is indicated to decrease the accumulation of organisms. If the patient is not taking oral nutrition, it is not a concern at this time. Oral care is not indicated if the patient is being suctioned on a regular basis
Ans: B Oral care is indicated to decrease the accumulation of organisms. Rationale: Oral care helps decrease the accumulation of organisms present in the mouth that can contribute to pneumonia and should be a regular part of postoperative care. Good oral care is important even if the patient is not eating, which actually serves to facilitate cleansing of the oral cavity. Protein will aid healing but does not negate the need for oral care.
The nurse is suctioning a patient's tracheostomy and notes a heart rate of 98 and an oxygen saturation of 89% during the procedure. Which action by the nurse is correct? Continue suctioning to fully clear the airway of secretions. Reoxygenate the patient with a 100% oxygen delivery system. Stop suctioning until the heart rate and oxygen saturation return to normal. Ask the patient to take three or four deep breaths before resuming suctioning.
Ans: B Reoxygenate the patient with a 100% oxygen delivery system. Rationale: If a patient becomes hypoxic during suctioning, the nurse should reoxygenate the patient with 100% oxygen. Patients are asked to take three to four deep breaths, if possible, prior to beginning suctioning. Continuing suctioning will increase the hypoxia.
Immediately after having a tracheostomy tube removed as ordered by the provider, the patient begins to cough and has difficulty breathing, talking, and clearing secretions. After notifying the provider, the nurse anticipates an order for which procedure? Reintubation Tracheal dilation Insertion of an oral airway Placement of a nasogastric tube
Ans: B Tracheal dilation Rationale: This patient shows signs of tracheal stenosis characterized by increased cough, difficulty breathing and talking, and decreased ability to clear secretions. Tracheal dilation is usually necessary to open the trachea. Insertion of an oral airway does not open the trachea. Placement of a nasogastric tube is not indicated. Reintubation will make the tracheal stenosis worse.
When suctioning a tracheostomy or endotracheal tube, what nursing actions ensure safe and effective practice? Select all that apply. Not suctioning longer than 20 seconds If needed, repeating suctioning up to three passes When suctioning, using a gentle twirling motion of the catheter Adjusting the pressure dial on the suction source to 120-160 mm Hg Applying suction while quickly inserting the catheter and slowly removing it Preoxygenating the patient with 100% oxygen for 30 seconds to 3 minutes before suctioning
Ans: B, C, F If needed, repeating suctioning up to three passes. When suctioning, using a gentle twirling motion of the catheter. Preoxygenating the patient with 100% oxygen for 30 seconds to 3 minutes before suctioning Rationale: Preoxygenation is a proactive strategy to diminish suction-related hypoxemia. The technique of suctioning using a gentle twirling motion diminishes the risk of mucosal injury. No more than three suctioning passes are recommended to minimize hypoxemia, tissue hypoxia, and related complications. The recommended negative pressure for suction is 80-120 mm Hg. Suction should not be applied during catheter insertion, but rather only during removal. The rule is not to suction more than 10 to 15 seconds to prevent hypoxia and complications.
Which laboratory tests provide valuable information to the nurse when caring for a patient requiring oxygen therapy? Select all that apply. Serum magnesium Arterial blood gases White blood cell count Hemoglobin and hematocrit Partial thromboplastin time (PTT)
Ans: B, D ABGS. Hemoglobin and hematocrit Rationale: Hemoglobin and hematocrit indicate oxygen-carrying capacity and therefore play a vital role in evaluating oxygenation. Arterial blood gases directly measure alveolar gas exchange and oxygenation. White blood cell count, PTT, and serum magnesium do not directly reflect oxygenation.
A patient with a tracheostomy is at increased risk for aspiration. Which nursing interventions will reduce this risk? Select all that apply. Encourage water with meals. Provide small, frequent meals. Encourage frequent sipping from a cup. Inflate the tracheostomy cuff during meals. Maintain the patient upright for 30 minutes after eating. Teach the patient to "tuck" the chin down in the forward position to swallow.
Ans: B, D, E Provide small, frequent meals. Maintain the patient upright for 30 minutes after eating. Teach the patient to "tuck" the chin down in the forward position to swallow. Rationale: 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. Eating requires significant time and energy; when the patient becomes tired, he is more likely to aspirate. Shorter and more frequent intervals of eating tire the patient less and reduce the chance of aspiration. Tucking the chin downward helps to open the upper esophageal sphincter. Liquids should not be given frequently and should be taken using a spoon to ensure that the patient is attempting to swallow only small volumes of liquid; thin liquids such as water are easily aspirated. The tracheostomy cuff should be deflated because an inflated tube narrows the upper esophageal sphincter opening, which increases the risk for aspiration.
A registered nurse is educating nursing students about precautions to prevent aspiration during swallowing in patients with tracheostomy tubes in place. Which nursing student statements require further teaching? Select all that apply. "I'll avoid giving fruit to the patient." "I'll give water and other 'thin' liquids to the patient." "I'll provide smaller and more frequent meals for the patient." "I'll position the patient in the most relaxed position possible." "I'll avoid serving meals to the patient when the patient is fatigued." "I'll assist the patient in turning in bed at regular intervals."
Ans: B, D, F "I'll give water and other 'thin' liquids to the patient.""I'll position the patient in the most relaxed position possible." "I'll assist the patient in turning in bed at regular intervals." Rationale: While caring for patients with tracheostomy tubes in place, the nurse should take precautions to prevent aspiration during swallowing. The nurse should avoid giving fruit to the patient, because fruits generate thin liquids during the chewing process. Water and other "thin" liquids should not be given to the patient. The patient should be positioned in the most upright position possible. The patient should be turned at regular intervals to reduce the risk for pressure ulcers, not to reduce the risk for aspiration. The nurse should provide smaller and more frequent meals for the patient and avoid serving meals when the patient is fatigued.
The health care provider has suggested placing a patient with chronic obstructive pulmonary disease (COPD) on noninvasive positive-pressure ventilation (NPPV) to improve gas exchange. What information is important to discuss with the patient before starting NPPV? Select all that apply. Pneumonia is a common associated risk. Tight-fitting masks can lead to skin breakdown. Mask leaks can cause pressure around the eyes. NPPV may require nasal gastric tube placement. There is a risk of aspiration due to gastric inflation.
Ans: B,C,D,E Tight-fitting masks can lead to skin breakdown. Mask leaks can cause pressure around the eyes. NPPV may require nasal gastric tube placement. There is a risk of aspiration due to gastric inflation. Rationale: NPPV masks must fit tightly in order to form a proper seal, which can lead to skin breakdown over the bridge of the nose or other areas of the face. Leaks can cause uncomfortable pressure around the eyes, and gastric insufflation can lead to vomiting and the potential for aspiration. A nasogastric tube may be required for safety. Ventilator-associated pneumonia is a risk associated with intubation, not NPPV.
A patient with sleep apnea has a new prescription for a BiPAP device to be worn at night. What does the nurse include in the teaching for this assistive device? Select all that apply. The BiPAP device only delivers room air. The mask must fit tightly to form a proper seal. BiPAP provides the same pressure during inhalation and exhalation. BiPAP provides positive pressure during inhalation and exhalation to keep alveoli open. BiPAP improves airflow during sleep and promotes comfort by reducing dyspnea.
Ans: B,D,E The mask must fit tightly to form a proper seal. BiPAP provides positive pressure during inhalation and exhalation to keep alveoli open. BiPAP improves airflow during sleep and promotes comfort by reducing dyspnea. Rationale: To ensure delivery of prescribed positive-pressure breaths, the mask must fit snugly with no leakage. The BiPAP device delivers positive-pressure ventilation to keep alveoli open and prevent atelectasis. It promotes rhythmic breathing and prevents apneic episodes, which cause dyspnea, thereby promoting comfort and restful sleep. It delivers oxygen as well as room air. The difference and benefit of BiPAP over the continuous positive airway pressure (CPAP) machine is that exhalation pressure is less than inspiratory pressure in BiPAP, providing less resistance and enhanced comfort.
The nurse assesses a patient with pneumonia who has been receiving oxygen 45% via Venturi mask for 2 days and notes dyspnea when getting to a chair and a nonproductive cough. The patient reports chest pain below the sternum and gastrointestinal (GI) upset. Which initial action by the nurse is correct? Request an order for arterial blood gases. Increase the oxygen to 50% via facemask. Contact the provider to report these findings. Notify the Rapid Response Team immediately.
Ans: C Rationale: This patient is manifesting signs of oxygen toxicity, and the nurse should notify the provider. The patient does not need an increase in oxygen. The chest pain is related to oxygen toxicity and not myocardial infarction, so the Rapid Response Team is not needed. The provider may order arterial blood gases.
A patient who has thick, sticky respiratory secretions requires high-flow, humidified oxygen delivery. Which oxygen delivery equipment does the nurse use for this patient? Face tent Venturi mask Aerosol mask Nonrebreather mask
Ans: C Aerosol mask Rationale: An aerosol mask is used when high humidity is needed, as with thick secretions. A face tent is used for patients with burns or facial trauma. A nonrebreather mask is a low-flow oxygen delivery system. The Venturi mask is not the best method to deliver high-humidity oxygen.
Which symptom indicates tube obstruction in a patient with tracheostomy? Quiet respirations Thick, wet secretions Difficulty in breathing Identified peak pressures
Ans: C Difficulty in breathing
An older patient receiving mechanical ventilation with a tracheostomy has poor nutritional status and is dehydrated. Which nursing action is most important to prevent complications in this patient? Provide warm, humidified air and suction the tube frequently. Encourage the patient to cough frequently to clear secretions. Keep the pressure on the tracheal tube cuff between 14 and 20 mm Hg. Change the tracheostomy tube dressing and reposition the tube every 4 hours
Ans: C Keep the pressure on the tracheal tube cuff between 14 and 20 mm Hg. Rationale: Older patients and those who are malnourished and dehydrated are at increased risk for tissue breakdown caused by tracheostomy tube pressure. Anything that causes movement of the tube causes friction and can contribute to tissue breakdown. Maintenance of cuff pressure between 14 mm Hg and 20 mm Hg will allow adequate circulation to the tracheal mucosa. The nurse should change dressings and suction the tube only as needed, taking care not to move the tube. Coughing will increase tube friction.
Which of these oxygen delivery systems is known to deliver low-flow fraction of inspired oxygen (FiO 2)? Face tent Venturi mask Nasal cannula Tracheostomy
Ans: C Nasal Cannula Rationale: The nasal cannula is the only type of oxygen delivery system which delivers low-flow FiO 2. Face tents, Venturi masks, and tracheostomies are examples of oxygen delivery systems that deliver high-flow FiO 2.
When assessing the adequacy of a patient's oxygenation, which information is important for the nurse to note? Fraction of inspired oxygen (Fio 2) Positive end-expiratory pressure (PEEP) Partial pressure of arterial oxygen (PaO 2) The patient's acceptance of the continuous positive airway pressure (CPAP) machine.
Ans: C Partial pressure of arterial oxygen (PaO 2) Rationale: PaO 2 is a measure of the amount of oxygen in the arterial blood. Fio 2 is a measure of the inspired oxygen, which may not all be absorbed. PEEP is a measure of positive expiratory pressure for a patient on a ventilator. CPAP is a delivery system, not a measure of oxygenation.
The risk for aspiration with a tracheostomy tube in place is related to which factor? Capping the tracheostomy tube for speaking Amount of xerostomia experienced by the patient Proximity of the tracheostomy tube to the epiglottis Increased length of time tracheostomy tube has been in place
Ans: C Proximity of the tracheostomy tube to the epiglottis Rationale: Because of the close proximity of the trachea to the esophagus, a tracheostomy tube can interfere with protecting the airway during swallowing. This increases the risk for aspiration. Capping the tracheostomy tube for speaking has not been shown to increase aspiration events. Although xerostomia will make eating more challenging, it doesn't directly cause an increased risk of aspiration. The longer the tracheostomy tube is in place, the less risk there is for aspiration.
Which instance would make the treatment with continuous positive airway pressure (CPAP) ineffective? Atelectasis after surgery Cardiac-induced pulmonary edema Respiratory failure following extubation Chronic obstructive pulmonary disease (COPD)
Ans: C Respiratory failure following extubation Rationale: CPAP has been found ineffective for patients with respiratory failure following extubation. Atelectasis is commonly seen in patients who have undergone surgery. Patients with cardiac-induced pulmonary edema and COPD may benefit from this form of oxygen or air delivery.
Which action is a priority safety precaution when performing tracheostomy care? Assessing for skin breakdown Replacing the disposable cannula Securing new ties before removing the old ones Cleaning the stoma with half-strength hydrogen peroxide
Ans: C Securing new ties before removing the old ones Rationale: Keeping the tube in place to prevent accidental decannulation is critical. Old ties or Velcro should be kept in place until the new ones are secure. Cleaning the stoma, replacing the disposable cannula, and assessing for skin breakdown are important, but maintaining the placement of the tube is the priority.
What is one of the purposes of oxygen therapy? To cure the problem To stop the disease process To have an acceptable blood oxygen level To use the highest fraction of inspired oxygen
Ans: C To have an acceptable blood oxygen level Rationale: One of the purposes of oxygen therapy is to have an acceptable blood oxygen level without causing harmful side effects. Oxygen therapy cannot cure a problem or stop a disease process. The lowest fraction of inspired oxygen is used.
What does the nurse include in the discharge teaching of a patient with a laryngectomy and tracheostomy? Cover the airway loosely with plastic wrap when showering. Use a dehumidifier in the home if secretions become excessive. Use colored seam binding as tracheostomy ties after the stoma has matured. When coughing, place a finger over the tracheostomy to expectorate secretions through the mouth.
Ans: C Use colored seam binding as tracheostomy ties after the stoma has matured. Rationale: Choosing colored seam binding that blends with the patient's clothing may enhance body image. Secretions are expectorated through the tracheostomy. Plastic wrap would create a risk for suffocation and is contraindicated. A shower shield is recommended during bathing or showering. A humidifier is recommended to liquefy tracheal secretions and facilitate airway clearance.
What is the greatest priority while providing care to a patient with a tracheostomy? Ensuring the area behind the faceplate is kept clean and dry Assessing for redness and skin breakdown around the tracheostomy When changing the ties, having someone assist by holding the tube until it is securely stable Encouraging the patient and family members to participate in tracheostomy care
Ans: C When changing the ties, having someone assist by holding the tube until it is securely stable Rationale: Unless the tube is well secured when providing tracheostomy care and changing the ties, dislodgement or decannulation may occur. Potential loss of airway is a priority over potential for skin breakdown or patient/family teaching.
The spouse of a patient who is scheduled for a tracheostomy is expressing concern regarding the surgery's impact on their quality of life. What should the focus of the nurse be at this time? Providing information about how to perform emergency resuscitation Emphasizing just getting through the surgery and postoperative period Teaching about the techniques explained previously for tracheostomy care Addressing approaches for the patient to communicate with the tracheostomy
Ans: D Addressing approaches for the patient to communicate with the tracheostomy Rationale: Various methods of nonverbal communication should be tried to determine the best approach to allow the couple to discuss their concerns and approaches for maintaining quality of life. Although it is important for the spouse to learn tracheostomy care and emergency procedures like resuscitation, concern for quality of life will potentially interfere with mastery of the content and skills.
A patient is receiving oxygen therapy. What are potential sources of infection the nurse should address? Select all that apply. Oxygen tubing pulling on the airway Use of nonpetroleum lotion for dry skin Use of a heated humidifier or nebulizer Use of an oral suction catheter in the endotracheal tube Rising white blood cell count noted on recent blood work
Ans: C,D Use of a heated humidifier or nebulizer. Use of an oral suction catheter in the endotracheal tube Rationale: Humidifiers and nebulizer containers can harbor organisms, which can lead to infections in patients receiving oxygen therapy. Organisms in the oral cavity can cause respiratory infections when transferred to the trachea via a suction catheter. Although oxygen tubing tension on an airway can cause pressure and potential breakdown, the more immediate concerns are the heated fluid in the containers and transference via suction catheters. The nonpetroleum lotions are preferred for dry skin that can result from oxygen therapy. A rise in the white blood cell count may indicate the presence of an infection, but it is not a source of infection.
Low-flow oxygen delivery systems typically include which types of components? Select all that apply. Venturi mask Aerosol mask Simple facemask T-piece apparatus Nonrebreather mask
Ans: C,E Simple facemask, nonrebreather mask Rationale: Both simple and non-rebreather facemasks can deliver a low level of oxygen. The Venturi (or Venti) and aerosol masks are used in high-flow oxygen delivery systems and are set up to deliver 24% to 50% Fio 2 and 24% to 100% Fio 2, respectively. The T-piece apparatus is an adapter that is attached to an endotracheal or tracheostomy tube.
When caring for a patient with a Venturi mask, one strategy to reduce the fraction of inspired oxygen (Fio 2) yet maintain oxygenation is to convert to which device? Nasal cannula Simple facemask Partial rebreather mask Continuous positive airway pressure mask (CPAP)
Ans: D CPAP Rationale: The CPAP mask administers continuous positive airway pressure, which increases ventilation by increasing volume and pressure of inhalation. This prevents alveolar collapse, thereby enhancing gas exchange/oxygenation, which would allow for lower Fio 2. Other delivery systems do not enhance ventilation.
The nurse assesses a patient who is receiving oxygen using a partial rebreather facemask at a flow rate of 12 L/min. The nurse notes the patient's oxygen saturation level is 90%. Which action would the nurse take next? Obtain arterial blood gases. Notify the Rapid Response Team. Increase the oxygen flow rate to 15 L/min. Change the mask to a non-rebreather mask.
Ans: D Change the mask to a non-rebreather mask. Rationale: Patients receiving oxygen by mask are prone to rebreathing exhaled air containing carbon dioxide and room air that has a lower oxygen concentration. A non-rebreather mask can deliver an FiO 2 greater than 90% at a flow rate of 10-15 L/min. Blood gases are not necessary in a patient with a saturation of 90%. There is no indication of respiratory instability in the patient described, so the Rapid Response Team is not needed. The partial rebreather only allows an oxygen flow rate of 6-11 L/min., so an increase to 12 L/min is not a correct action.
A new graduate RN discovers that her patient, 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? Replace the obturator while reinserting the tracheostomy tube. Auscultate the patient's breath sounds while applying a nasal cannula. Apply a 100% non-rebreather mask while administering high-flow oxygen. Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask.
Ans: D Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask. Rationale: Because a fresh tracheostomy stoma will collapse, the patient will lose airway patency, which will require the nurse to ventilate the patient through the mouth and nose while waiting for assistance to recannulate the patient. Directing someone else to call the Rapid Response Team allows the nurse to provide immediate care required by the patient. Auscultation of the patient's breath sounds at this time will not improve the patient's respiratory status and will be ineffective until airway patency is restored. Further, auscultation should not be done while a nasal cannula is simultaneously applied. Effective use of a 100% non-rebreather mask requires a patent airway. During the first 72 hours following a tracheostomy, reinsertion of the tube is difficult and should not be attempted by the nurse. Reinsertion of the tracheostomy tube should be done once a Rapid Response Team is available to accomplish this.
A patient receiving oxygen via nasal cannula at a rate of 4 L/min reports irritation of the nose, and the nurse notes dry, reddened nostrils. Which action by the nurse is correct? Lower the oxygen flow rate to 2 L/min. Change the nasal cannula to a facemask. Apply petrolatum ointment to the patient's nostrils. Notify respiratory therapy for humidification per provider order.
Ans: D Notify respiratory therapy for humidification per provider order. Rationale: The nurse should collaborate with respiratory therapy to humidify the oxygen if the patient is receiving oxygen at a rate of 4 L/min or more. The nurse may apply a nonpetrolatum cream to the nostrils. It is not necessary to change to a facemask at this liter flow and without trying other comfort measures first. The nurse should not lower the liter flow unless the patient's provider orders this or the patient meets criteria, such as adequate oxygen saturation.
The nurse is preparing to change a cuffed tube tracheostomy to a fenestrated tracheostomy tube. Which action is most important prior to cuff deflation? Ask the patient to perform the Valsalva maneuver. Insert an oral airway to prevent airway obstruction. Teach the patient how to use an incentive spirometer. Suction the patient's oropharynx before deflating the cuff.
Ans: D Suction the patient's oropharynx before deflating the cuff. Rationale: Before deflating a cuff, the nurse should suction the airway above the cuff to remove any secretions that might be aspirated into the lungs. It is not necessary for the patient to perform the Valsalva maneuver or for the nurse to insert an oral airway. An incentive spirometer is not indicated.
A patient who has experienced a panic attack is being transferred to the medical-surgical ward. The transfer nurse reports that the patient is doing much better after receiving bronchodilators via nebulizer and a small dose of oral diazepam 4 hours ago in the emergency department. Vital signs are stable with oxygen delivered at 4 L/min via simple facemask. Why is this patient at high risk for subsequent respiratory distress? The patient has a mental disorder. The patient received a dose of diazepam. The patient is not being treated for asthma. The patient is receiving oxygen at 4 L/min.
Ans: D The patient is receiving oxygen at 4 L/min. Rationale: 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 patient. The patient had a panic attack, not an asthma attack. A panic attack is not a definitive diagnostic indicator of a mental disorder. A small dose of diazepam does not place a patient at increased risk for respiratory distress; a large dose is required to place a patient at high risk.
Which condition causes subcutaneous emphysema in a patient with a new tracheostomy? Hemorrhage from a nicked artery Effusion from fluid in the pleural space Inflammation from an infectious process Trapping of air escaped into the tissues
Ans: D Trapping of air escaped into the tissues Rationale: Subcutaneous emphysema occurs when there is an opening or tear in the trachea and air escapes into the fresh tissue planes of the neck. Air can also progress throughout the chest and other tissues into the face. Hemorrhage from a nicked artery, effusion of fluid in the pleural space, and inflammation from an infectious process are all possible complications related to a new tracheostomy, but they do not cause subcutaneous emphysema.
For patient safety and quality care, which technique is best for the nurse to use when suctioning the patient with a tracheostomy tube? Suction for 30 seconds. Repeat suctioning until the tube is clear. Apply suction during insertion of the tube. Hyperoxygenate before and after suctioning.
Ans:D Hyperoxygenate before and after suctioning. Rationale: The patient should be preoxygenated with 100% oxygen for 30 seconds to 3 minutes to prevent hypoxemia. After suctioning, the patient should be hyperoxygenated for 1 to 5 minutes or until the patient's baseline heart rate and oxygen saturation are within normal limits. Repeat suctioning as needed for up to three total suction passes; additional suctioning will cause or worsen hypoxemia. Applying suction during insertion is inappropriate because suction makes advancement of the suction tube difficult/traumatic. Suction is applied only when the suction tube is removed. Suctioning for 30 seconds is too long and can cause or worsen hypoxemia; never suction longer than 10 to 15 seconds.