Chapter 36: Airway Management

A nurse is providing tracheostomy care for a client. After removing the plastic inner cannula, which would the nurse do next?

Place the cannula in the diluted hydrogen peroxide.

An older adult client requires frequent suctioning because of copious secretions. The client currently is experiencing multiple health problems. During suctioning attempts, the nurse monitors the client's:

heart rhythm

A client returns to the unit following an insertion of a tracheostomy tube. Where should the nurse place the obturator?

Place the obturator in a plastic bag and put it at the bedside

A client with a 26-year history of cigarette smoking is recovering from pneumonia. Which information will be most important for the nurse to include in the discharge teaching?

options for smoking cessation

A nurse has an order to collect a sputum specimen on a client admitted with acute bronchitis. When will be the best time to collect the specimen?

just after the client wakes up

Which physiologic change does the nurse anticipate will be found in the older adult client with an ongoing nonproductive cough?

laryngeal atrophy

The nurse is caring for a client with ineffective airway clearance. Which food will the nurse remove from the client's dietary tray?

milk

The nurse is preparing a client for a tracheostomy insertion with a fenestrated tracheostomy tube. Which statement made by the client indicates an accurate understanding of the fenestrated tube?

"I'm glad I will still be able to talk once I get this tube inserted."

The client measures the distance from the client's front teeth to the angle of the jaw as slightly more than 3 inches. The nurse is to insert an oral airway and selects one that measures:

80 mm

What can a nurse ask a client to do before suctioning to prevent hypoxemia?

Take several deep breaths.

A client has had a tracheostomy and the nurse is prepared to conduct tracheostomy care. What part of the tracheostomy tube is removed for cleaning?

inner cannula

A client with a head injury will require long-term airway support. Which device will be required for this client?

tracheostomy tube

The nurse is assessing a client with a history of asthma. Which assessment finding indicates that the nurse should take immediate action?

use of accessory muscles in breathing

A nurse is taking the health history of an older adult. Which factor would raise the nurse's concern about potential pathologic changes in the client's pulmonary system?

working 20 years in a factory

A nurse is collecting a sputum specimen from a client. How much sputum should the nurse collect?

1 to 3 mL

A nurse is teaching a client about postural drainage. What is the maximum duration, in minutes, that a client should hold each of the prescribed positions? Record your answer using a whole number.

45

A nurse at the health care facility collects a sputum specimen of a client with pneumonia for a laboratory test. Which actions should the nurse perform after collecting the specimen?

Attach a label and laboratory request form to the specimen.

What is the rationale for placing a writing board in the room of a client who has had surgery to insert a tracheostomy tube?

The client is not able to speak.

The client is prescribed postural drainage two times per day at home. When reinforcing client instructions, the nurse states:

Cough sputum into paper tissues."

A nurse is preparing to insert an oral airway. The nurse would position the client supine with the neck in which position?

Hyperextension

Why is keeping clients with respiratory disorders well hydrated an important nursing intervention?

It thins mucus, promoting its expectoration.

A client is recovering from a recent stroke and the care team suspects that the client has been aspirating food, despite the use of a high-texture diet. Aspiration of food and liquids into the lungs is associated with what nursing diagnoses? Select all that apply.

Risk for Infection Ineffective Airway Clearance Impaired Gas Exchange Ineffective Breathing Pattern

A physician orders an oropharyngeal airway to be inserted into a client. What accurately describes the use of this device?

The nurse can insert this device at the bedside with little to no trauma to the unconscious client.

Which older adult clients are at increased risk for aspiration? Select all that apply.

Those who report, "I have trouble swallowing" Those with late-stage dementia Those who are hospitalized following a stroke Those recovering from general anesthesia

A nurse is caring for a client who underwent a tracheostomy (trach) following throat surgery. What is the rationale for swabbing the area around the outside of the trach tube with hydrogen peroxide?

To remove encrusted secretions

The client has a chest incision under the left arm from cardiac surgery 1 week ago. The client now has pneumonia and has percussion during postural drainange prescribed. The nurse:

avoids striking the area under the left arm

Nursing students are reviewing the structures of the airway. The students demonstrate understanding of the information when they identify what as responsible for moving collected debris upward?

cilia

Students are reviewing information about mobilizing secretions. The students demonstrate a need for additional teaching when they identify what as a technique of chest physiotherapy?

oxygen administration

A nurse is preparing to suction a client through a previously inserted oral airway. What are the most appropriate actions of the nurse before beginning the procedure? Select all that apply.

Wash hands. Pre-oxygenate the client. Open the suction kit.

The nurse is preparing to suction a client's airway. How long will the nurse preoxygenate the client to achieve a maintenance Sp02 of 95-100%?

1-2 minutes

The nurse is preparing to perform nasopharyngeal suctioning on an adult using a wall unit. What is the appropriate suction pressure setting for an adult?

100 to 120 mm Hg

A nurse is preparing to perform oral suctioning of a 40-year-old client. The nurse attaches the suction catheter and tubing to wall suction and sets the suction pressure at which level?

110 mm Hg

A nurse is reviewing home care measures with a client who must perform postural drainage. The nurse advises the client to perform the exercise how often?

2 to 4 times/day

The nurse is caring for four clients. Which client does the nurse identify that would best benefit from chest physiotherapy?

21-year-old client with cystic fibrosis

An older adult client with a history of chronic obstructive pulmonary disease is admitted to the hospital with a cough and acute shortness of breath. Which priority action should the nurse take during the initial assessment of the client?

Ask specific questions about history of the cough and shortness of breath.

Which technique would the nurse employ to maximize the effectiveness of postural drainage?

Combine it with percussion and vibration.

A nurse is teaching a client and her family about postural drainage. What should be included in the teaching plan? Select all that apply.

Complete postural drainage four times a day. Cough out any expectorated sputum in a tissue and dispose of properly. Return to a comfortable position when tired, lightheaded, or short of breath.

A nurse on an acute geriatric unit of the health care facility provides care for many clients who are being treated for pneumonia. What age-related change predisposes older adults to pneumonia?

Decreased ability of cilia to clear debris from the lower airway

A sputum specimen is to be collected from a client. What would the nurse do?

Encourage a forceful cough to expectorate sputum.

A client with chronic obstructive pulmonary disease (COPD) has Ineffective Airway Clearance related to retained secretions as manifested by weak and persistent cough. Which action by the nurse would be most appropriate?

Encourage the client to sit up, lean slightly forward, and cough forcefully.

A client is being treated with intravenous antibiotics for pneumonia, a health problem that has been accompanied by production of copious, thick respiratory secretions. How can the nurse best reduce the viscosity (thickness) of the client's secretions?

Ensure that the client's fluid intake is sufficient at all times

A nurse is preparing to suction a client. Place the suction procedure in the correct order.

Gather equipment. Adjust suction to 120 to 150 mm Hg with tubing occluded. Provide pre-oxygenation. Set up sterile field and apply gloves. Insert catheter without suction approximately 5 to 6 inches. Withdraw catheter, applying intermittent suction and oxygenate the client.

A nurse has an order to obtain a sputum specimen on a newly admitted client. Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?

Label the sputum specimen and take it to the lab.

A nurse is teaching a client and family about performing postural drainage. The nurse instructs the client to stop the procedure and resume a comfortable position if which of the following happens? Select all that apply.

Lightheadedness Rapid pulse rate Fatigue Difficulty breathing

A nurse has just completed tracheal suctioning on a client. Which finding would the nurse interpret as indicating that the treatment was effective?

Lungs clear on auscultation

The nurse has a nursing diagnosis of Ineffective Airway Clearance related to retained secretions as evidenced by moist lung sounds, respiratory rate of 28 to 30 breaths per minute, and ineffective cough. Appropriate nursing interventions include which of the following? Select all that apply.

Monitor respiratory rate every hour and as needed. Auscultate lung sounds every 2 hours.

A client is ordered to receive nasopharyngeal suctioning every 2 hours. Which of the following would the nurse anticipate using as a protective measure for the client?

Nasopharyngeal trumpet

A nurse is assisting a client with inhalation therapy. What does inhalation therapy administer to the client? Select all that apply.

Oxygen Humidification Aerosolized medications

The nurse is evaluating the effectiveness of therapy for a client who has received inhalation therapy treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective?

Oxygen saturation is > 94%

A nurse is preparing to assist a client with chest physiotherapy. Which of the following materials would the nurse have on hand? Select all that apply.

Paper tissues Waterproof container

The nurse is to obtain a sputum specimen from the client. Which actions should the nurse perform? Select all that apply.

Plan to collect the sputum in the morning Assist the client to a sitting position

A nurse is preparing to insert an oral airway on an unconscious client. How should the nurse proceed?

Position the client with the neck hyperextended.

A nurse is caring for a client who is recovering from general anesthesia after cardiac surgery. The nurse uses an oral airway for airway management for this client. What is the purpose of an oral airway?

Prevents obstruction of the upper airway

A nurse is using inhalation therapy with a client. Which would not be administered through this method?

Protein therapy

A client with a new tracheostomy is becoming frustrated because of his inability to speak. Which intervention will enhance his ability to communicate?

Providing the client with a communication board and keep the call bell within reach.

The nurse is to suction the nasopharynx of a client. No equipment is in the room. There is a wall outlet for suctioning. Which equipment does the nurse gather? Select all that apply

Suction kit Suction canister Connecting tubing 500-mL container of sterile saline

The nurse is to suction the nasopharynx of a client. No equipment is in the room. There is a wall outlet for suctioning. Which equipment does the nurse gather? Select all that apply.

Suction kit Suction canister Connecting tubing 500-mL container of sterile saline

A nurse is observing a new graduate suctioning a client's tracheostomy tube. Which intervention would cause the nurse to intervene?

Suction was applied when the catheter was inserted.

A nurse is performing tracheostomy care. The nurse cleans the inner cannula and then rinses it in the basin of normal saline. To complete the procedure, the nurse performs additional actions. Place them in the order in which the nurse would complete them, from first step to last.

Tap the rinsed cannula against the edge of the basin, wiping excess solution off with a gauze square. Replace the inner cannula, turning it clockwise within the outer cannula to secure it. Clean around the stoma with applicators moistened with diluted hydrogen peroxide. Place the sterile stomal dressing beneath the flanges and outer cannula of the tracheostomy. Change the tracheostomy ties, threading them through the slits of each flange.

Which statements accurately describe a step for inserting an oropharyngeal airway? (Select all that apply.)

Use an airway that is the correct size (size 90 mm is appropriate for the average adult). Airway should reach from opening of mouth to the back angle of the jaw. Nurse should open client's mouth by using thumb and index finger to gently pry teeth apart. Insert the airway with the curved tip pointing up toward the roof of the mouth.

A client has just returned from getting a new tracheostomy inserted. When the nurse enters the room, the client is cyanotic, with the tracheostomy tube lying on the bed. What is the nurse's priority action?

Ventilate the client with a resuscitation bag with mask.

A nurse is performing chest physiotherapy on an older adult client with chronic obstructive pulmonary disease who needs assistance mobilizing secretions. While performing vibration, when should the nurse use the palms of her hands to shake underlying tissue and loosen retained secretions.

When the client is exhaling

A nurse is preparing to orally suction a client with dysphagia following a stroke. Which suction device is appropriate?

Yankauer catheter

The client has a nursing diagnosis of Ineffective Airway Clearance related to retained secretions as evidenced by moist lung sounds, respiratory rate of 28 to 30 breaths per minute, and ineffective cough. The nurse evaluates client outcome and determines the outcome is met when the client demonstrates:

clear lung sounds

The nurse is caring for an older adult client with pathologic pulmonary changes. The nurse should be aware that which conditions cause pathologic pulmonary change? Select all that apply.

clients with a history of smoking occupations where clients have inhaled pollutants clients residing in an area with toxic emission

A nurse is caring for an unconscious client with an oral airway. What should the nurse include in the plan of care?

cough

A nurse is completing tracheostomy suctioning on an older adult client. Which would be an indication to stop suctioning?

dysrhythmias

The physician at the health care facility directs the nurse to perform vibration along with percussion on a frail client with a respiratory diagnosis. What is a possible outcome of performing vibration on the client?

helps shake underlying tissue and loosen the retained secretion

A nurse is taking the health history of an older adult. Which factors in the client's history would raise the nurse's concern about potential pathologic changes in the client's pulmonary system? Select all that apply.

history of cigarette smoking occupation that involves inhaling pollutants living in a heavily industrialized area

The client has thick secretions and an ineffective cough. The nurse selects the following fluid to administer to the client

iced tea

The client has a tracheostomy and is producing copious secretions. Secretions are on the tracheostomy gauze. The nurse intervenes best by:

inserting the suction catheter 4 to 5 inches into the trachea

The client is producing copious secretions and requires frequent suctioning. The client does not have a tracheostomy. To protect the nostril, the nurse:

inserts a nasopharyngeal trumpet

The sedated client has an oxygen saturation that has dropped to 88%, a respiratory rate of 10 breaths per minute, and gurgling sounds when taking breaths. The best action of the nurse is to:

perform nasopharyngeal suctioning.

The physician directs the nurse to use oropharyngeal suctioning to remove liquid secretions for a client with a respiratory problem. What is oropharyngeal suctioning?

removing secretions from the throat through an orally inserted catheter

An alert client cannot cough up secretions and has gurgling sounds from the mouth. The best action of the nurse is to:

suction the mouth with a Yankauer-tip catheter.

The client is sedated following cervical spine surgery. The nurse notes secretions are accumulating in the client's throat. An oral airway is prescribed. Prior to inserting the airway, the nurse:

suctions the oropharyngeal area

The physician directs the nurse to use suctioning to remove liquid secretion from a 5-year-old client. If the nurse uses a portable suctioning machine, how much negative pressure should the nurse apply to drain the liquid secretion with a catheter

5 to 10 mm Hg

A nurse is performing nasopharyngeal suctioning. When inserting the catheter, the nurse would most likely advance the catheter to which distance?

5-6 inches

When performing suctioning to remove the liquid secretion from a client with chest congestion, what should the nurse do to prevent hypoxemia in the client?

Complete the process in no more than 15 seconds

"Swallowing down the wrong pipe" has happened to all of us. After a significant coughing spasm and gasping for air, we typically recover - none the worse for wear. Which upper airway structure malfunctions to cause the event?

Epiglottis