Chapter 37 Egans Respiratory

What is the primary indication for tracheal suctioning? Presence of pneumonia Presence of atelectasis Ineffective coughing Retention of secretions

D

A patient receiving mechanical ventilatory support accidentally displaces the endotracheal tube out of the trachea. What would be the most appropriate action at this time? Remove the tube and provide manual ventilation or oxygenation as necessary. Push the tube back into the trachea by moving the patient's neck up and down. Suction the oropharynx with a Yankauer (tonsillar) suction tip. Apply manual ventilation or oxygenation directly through the endotracheal tube.

a

A patient with a tracheostomy tube is receiving positive-pressure ventilation through a volume ventilator. Over the past 5 min, the peak inspiratory pressure has risen, and the pressure limit alarm is now sounding. On quick examination, you notice a generalized decreased in breath sounds. Which of the following problems is most likely? Partial obstruction of the tracheostomy tube Complete obstruction of the tracheostomy tube Development of a left-sided pneumothorax Obstruction of the left bronchus by a mucus plug

a

After determining a patient has a complete obstruction of an oral endotracheal tube, your efforts to relieve the obstruction by moving the patient's head and neck and deflating the cuff both fail. What should be your next step? Immediately remove the airway. Suction the patient. Call for an emergency tracheotomy. Apply manual positive pressure.

a

After intubation of a cardiac arrest victim, you observe a slow but steady rise in the expired CO2 levels as measured by a bedside capnometer. Which of the following best explains this observation? Return of spontaneous circulation Abnormally high Placement of the endotracheal tube in the esophagus Failure of the cuff to properly seal the airway

a

After removal of an oral endotracheal tube, a patient exhibits hoarseness and stridor that do not resolve with racemic epinephrine treatments. What is most likely the problem? Vocal cord paralysis Tracheoesophageal fistula Glottic edema or cord inflammation Tracheomalacia

a

An adult man on ventilatory support has just been intubated with a 7-mm oral endotracheal tube equipped with a high-residual-volume, low-pressure cuff. When sealing the cuff to achieve a minimal occluding volume, you note a cuff pressure of 45 cm H2O. What is most likely the problem? The tube chosen is too small for the patient. The cuff pilot balloon and line are obstructed. The tube is in the right main stem bronchus. The cuff has herniated over the tube tip.

a

Before beginning an intubation procedure, the practitioner should check and confirm the operation of which of the following? 1. Laryngoscope light source 2. Endotracheal tube cuff 3. Suction equipment 4. Cardiac defibrillator 1, 2, and 3 only 2 and 4 only 3 and 4 only 1, 3, and 4 only

a

During oral intubation of an adult, the endotracheal tube should be advanced into the trachea about how far? Until its cuff has passed the cords Just far enough so that the tube cuff is no longer visible Until its cuff has passed the cords by 2 to 3 in Until its tip has passed the cords by 2 to 3 cm

a

For which of the following purposes is a tracheal button appropriate? 1. Facilitate secretion removal. 2. Protect the airways from aspiration. 3. Relieve airway obstruction. 4. Aid in positive-pressure ventilation. 1 and 3 only 2 and 4 only 3 and 4 only 1, 2, 3, and 4

a

The removable inner cannula commonly incorporated into modern tracheostomy tubes serves which of the following purposes? 1. Aid in routine tube cleaning and tracheostomy care 2. Prevent the tube from slipping into the trachea 3. Provide a patent airway should it become obstructed 1 and 3 only 2 and 3 only 3 only 1, 2, and 3

a

What is the maximum recommended range for tracheal tube cuff pressures? 20 to 30 cm H2O 30 to 40 cm H2O 20 to 30 mm Hg 30 to 40 mm Hg

a

What is the normal range of negative pressure to use when suctioning an adult patient? -120 to -150 mm Hg -100 to -120 mm Hg -80 to -100 mm Hg -60 to -80 mm Hg

a

What is the purpose of a cuff on an artificial tracheal airway? To seal off and protect the lower airway To stabilize the tube and prevent its movement To provide a means to determine tube position via radiograph To help clinicians determine the depth of tube insertion

a

What is the purpose of a tracheostomy tube obturator? To minimize trauma to the tracheal mucosal during insertion To provide a patent airway should the tube become obstructed To help ascertain the proper tube position by radiograph To provide a means to inflate and deflate the tube cuff

a

What should be the maximum time devoted to any intubation attempt? 30 sec 60 sec 90 sec 2 min

a

When checking for proper placement of an endotracheal tube in an adult patient on chest radiograph, it is noted that the distal tip of the tube is 1 cm above the carina. Which of the following actions would you recommend? Withdraw the tube by 2 to 4 cm (using tube markings as a guide). Withdraw the tube by 7 to 8 cm (using tube markings as a guide). Advance the tube by 2 to 4 cm (using tube markings as a guide). Advance the tube by 7 to 8 cm (using tube markings as a guide).

a

When using capnometry or colorimetry to differentiate esophageal from tracheal placement of an endotracheal tube, which of the following conditions can result in a false-negative finding (i.e., no CO2 present even when the tube is in the trachea)? Cardiac arrest Gastric CO2 diffusion Right main stem intubation Delivery of a high FiO2

a

Which of the following features incorporated into most modern endotracheal tubes assist in verifying proper tube placement? 1. Length markings on the curved body of the tube 2. Imbedded radiopaque indicator near the tube tip 3. Additional side port (Murphy eye) near the tube tip 1 and 2 only 1 and 3 only 2 and 3 only 1, 2, and 3

a

Which of the following injuries are seen with tracheostomy tubes? 1. Tracheomalacia 2. Tracheal stenosis 3. Glottic edema 4. Vocal cord granulomas 1 and 2 only 3 and 4 only 2, 3 and 4 only 1, 2, and 3 only

a

Which of the following is an absolute contraindication for percutaneous dilation tracheostomy? Need for emergent surgical airway Children younger than 12 years of age Coagulopathy Pulsating blood vessel over tracheotomy site

a

You have been asked to monitor a patient who has just been extubated. Which of the following parameters would you monitor? 1. Color 2. Breath sounds 3. Vital signs 4. Inspiratory force 1, 2, and 3 only 2 and 4 only 3 and 4 only 2, 3, and 4 only

a

After an intubation attempt, an expired capnogram indicates a CO2 level near zero. What does this finding probably indicate? Abnormally high ventilation/perfusion ratio ( ) Placement of the endotracheal tube in the esophagus Placement of the endotracheal tube in the trachea Failure of the cuff to properly seal the airway

b

Although different techniques are used to actually remove the endotracheal tube during an extubation procedure, all aim to ensure which of the following? Maximal adduction of the vocal cords Maximal abduction of the vocal cords Maintenance of the appropriate cuff pressure Elimination of the pharyngeal (gag) reflex

b

An alert patient with a long-term need for a tracheostomy tube (because of recurrent aspiration) is having difficulty communicating with the intensive care unit staff. Which of the following would you recommend to help this patient communicate better? 1. Use a letter, phrase, or picture board. 2. Consider switching to a fenestrated tracheostomy tube. 3. Consider a "talking" tracheostomy tube. 1 and 2 only 1 and 3 only 2 and 3 only 1, 2, and 3

b

Before the suctioning of a patient, auscultation reveals coarse breath sounds during both inspiration and expiration. After suctioning, the coarseness disappears, but expiratory wheezing is heard over both lung fields. What is most likely the problem? Secretions are still present and the patient should be suctioned again. The patient has hyperactive airways and has developed bronchospasm. A pneumothorax has developed and the patient needs a chest tube. The patient has developed a mucous plug and should undergo bronchoscopy.

b

Compared with traditional surgical tracheostomy, which of the following are true about percutaneous dilatational tracheostomy? 1. Percutaneous dilatational tracheostomy has a lower incidence of complications. 2. Percutaneous dilatational tracheostomy is faster than traditional tracheostomy. 3. Percutaneous dilatational tracheostomy can be performed at the bedside. 4. Percutaneous dilatational tracheostomy does not require anterior neck dissection. 1 and 3 only 1, 2, and 3 only 3 and 4 only 2, 3, and 4 only

b

Compared with translaryngeal intubation, the advantages of tracheostomy include which of the following? 1. Greater patient comfort 2. Reduced risk of bronchial intubation 3. No upper airway complications 4. Decreased frequency of aspiration 1 and 3 only 1, 2, and 3 only 3 and 4 only 2, 3, and 4 only

b

Ideally, the distal tip of a properly positioned endotracheal tube (in an adult man) should be positioned approximately how far above the carina? 1 to 3 cm 3 to 6 cm 7 to 9 cm 4 to 6 in

b

In the absence of neck or facial injuries, what is the procedure of choice to establish a patent tracheal airway in an emergency? Surgical tracheotomy Orotracheal intubation Nasotracheal intubation Cricothyrotomy

b

Serious complications of oral intubation include which of the following? 1. Cardiac arrest 2. Acute hypoxemia 3. Bradycardia 4. Tongue lacerations 2 and 4 only 1, 2, and 3 only 2, 3, and 4 only 2, 3, and 4 only

b

To maintain positive end expiratory pressure (PEEP) and high FiO2 when suctioning a mechanically ventilated patient, what would you recommend? Limit suction time to no more than 5 sec. Use a closed-system multiuse suction catheter. Limit suctioning to once an hour. Use the smallest possible catheter.

b

To minimize laryngeal swelling, a physician orders "continuous aerosol therapy" after the extubation of a patient. Which of the following specific approaches would you recommend? Heated mist therapy through a jet nebulizer and aerosol mask Cool mist therapy through a jet nebulizer and aerosol mask Oxygen therapy through a "venti-mask" and bubble humidifier Racemic epinephrine or saline through a small jet nebulizer

b

To prevent hypoxemia when suctioning a patient, the respiratory care practitioner should initially do which of the following? Manually ventilate the patient with a resuscitator. Preoxygenate the patient with 100% oxygen. Give the patient a bronchodilator treatment. Have the patient hyperventilate for 2 min.

b

What is the normal range of negative pressure to use when suctioning children? -120 to -150 mm Hg -100 to -120 mm Hg -80 to -100 mm Hg -60 to -80 mm Hg

b

What is the primary indication for tracheostomy? When a patient loses pharyngeal or laryngeal reflexes When a patient has a long-term need for an artificial airway When a patient has been orally intubated for more than 24 hr When a patient has upper airway obstruction due to secretions

b

What is the purpose of an endotracheal tube stylet? It helps ascertain proper tube position. It adds rigidity and shape to ease insertion. It minimizes mucosal trauma during insertion. It protects the airway against aspiration.

b

What is the standard size for endotracheal or tracheostomy tube adapters? 22-mm external diameter 15-mm external diameter 15-mm internal diameter 22-mm internal diameter

b

What size endotracheal tube would you select to intubate a 1500-g newborn infant? 2.5 mm 3.0 mm 3.5 mm 4.0 mm

b

What size endotracheal tube would you select to intubate a 3-year-old child? 3.0 to 4.0 mm 4.5 to 5.0 mm 5.5 to 6.0 mm 6.0 to 7.0 mm

b

Which of the following are potential complication of suctioning? 1. Hypoxemia 2. Hypotension 3. Arrhythmias 4. Gastrointestinal distress 2 and 4 only 1, 2, and 3 only 1 and 3 only 1, 3, and 4 only

b

Which of the following can help to minimize the likelihood of mucosal trauma during suctioning? 1. Use as large a catheter as possible. 2. Rotate the catheter while withdrawing. 3. Use as rigid a catheter as possible. 4. Limit the amount of negative pressure. 1 and 3 only 2 and 4 only 3 and 4 only 1, 2, and 4 only

b

Which of the following equipment is needed to perform nasotracheal suctioning? 1. Suction kit (catheter, gloves, basin, etc.) 2. Laryngoscope with MacIntosh and Miller blades 3. Oxygen delivery system (mask and manual resuscitator) 4. Bottle of sterile water or saline solution 1 and 3 only 1, 3, and 4 only 2 and 4 only d. 2, 3, and 4 only

b

Which of the following is a reason to collect a sputum sample from a patient? Reduce the risk of accidental extubation Identify organisms infecting the airway Assess extubation readiness Improve mechanical ventilation synchrony

b

Which of the following statements are true about methods used to displace the epiglottis during oral intubation? a. Regardless of the blade used, the laryngoscope is lifted up and forward. b. The curved (MacIntosh) blade lifts the epiglottis indirectly. c. The straight (Miller) blade lifts the epiglottis directly. d. Levering the laryngoscope against the teeth can aid displacement. 1 and 3 only 1, 2, and 3 only 3 and 4 only 2, 3, and 4 only

b

While checking a Miller and a MacIntosh blade on an intubation tray during an emergency intubation, you find that the Miller blade "lights" but the MacIntosh blade does not. What should you do now? Swap the defective MacIntosh for the good Miller blade. Check and replace the bulb in the MacIntosh blade. Replace the batteries in the laryngoscope handle. Check and clean the laryngoscope handle electrical contact.

b

While suctioning a patient, you observe an abrupt change in the electrocardiogram waveform being displayed on the cardiac monitor. Which of the following actions would be most appropriate? Change to a smaller catheter and repeat the procedure. Stop suctioning and immediately administer oxygen. Stop suctioning and report your findings to the nurse. Decrease the amount of negative pressure being used.

b

A patient has been receiving positive-pressure ventilation through a tracheostomy tube for 4 days. In the past 2 days, there is evidence of both recurrent aspiration and abdominal distention but minimal air leakage around the tube cuff. What is most likely cause of the problem? Paralysis of the vocal cords Underinflated tube cuff Tracheoesophageal fistula Tracheoinnominate fistula

c

A patient with a tracheal airway exhibits severe respiratory distress. On quick examination, you notice the complete absence of breath sounds and no gas flowing through the airway. What is most likely the problem? Partial tube obstruction Right-sided pneumothorax Complete tube obstruction Vocal cord paralysis

c

After repeated nasotracheal suctioning over 2 days, a patient with retained secretions develops minor bleeding through the nose. Which of the following actions would you recommend? Perform a tracheotomy for better access to the lower airway. Discontinue nasotracheal suctioning for 48 hr and reassess. Stop the bleeding and use a nasopharyngeal airway for access. Orally intubate the patient for better access to the lower airway.

c

An adult patient receiving cool mist therapy after extubation begins to develop stridor. Which of the following actions would you recommend? Change from cool mist to heated aerosol. Re-intubate the patient immediately. Administer a racemic epinephrine treatment. Draw and analyze an arterial blood gas

c

How often should patients be suctioned? At least once every 2 to 3 hr Whenever they are moved or ambulated When physical findings support the need Whenever the charge nurse requests it

c

In a properly performed traditional surgical tracheotomy, entrance to the trachea is made through an incision in what area? Through or between the first and second tracheal rings Through the ligament between the thyroid and cricoid cartilages Through or between the second and third tracheal rings Between the cricoid cartilage and the first tracheal ring

c

Repeated connecting and disconnecting of a cuff pressure manometer to the pilot tube of a cuffed tracheal airway will do which of the following? Increase cuff pressure. Not affect cuff pressure. Decrease cuff pressure. Rupture the cuff.

c

Successful tube passage through the larynx during blind nasotracheal intubation is indicated by which of the following? 1. Louder breath sounds 2. Harsh cough 3. Vocal silence 1 and 2 only 1 and 3 only 2 and 3 only 1, 2, and 3

c

To provide local anesthesia and vasoconstriction during nasal intubation, what would you recommend? Nasal spray of 0.25% phenylephrine SVN aerosol delivery of 2% lidocaine for 10 min Mixture of 0.25% phenylephrine and 3% lidocaine SVN aerosol delivery of 0.25% phenylephrine for 10 min

c

Total application time for endotracheal suction in adults should not exceed which of the following? 20 sec 15 sec 10 sec 3 sec

c

What is the average distance from the tip of a properly positioned oral endotracheal tube to the incisors of an adult man? 16 to 18 cm 19 to 21 cm 21 to 23 cm 24 to 26 cm

c

What is the most common problem with fenestrated tracheostomy tubes? Relative frequency of accidental extubation Increased likelihood of tracheomalacia Poor positioning of the tube fenestration Inability to provide mechanical ventilation

c

What is the normal range of negative pressure to use when suctioning infants? -120 to -150 mm Hg -100 to -120 mm Hg -80 to -100 mm Hg -60 to -80 mm Hg

c

What is the purpose of the pilot balloon on an endotracheal or a tracheostomy tube? To help ascertain proper tube position To minimize mucosal trauma during insertion To monitor cuff status and pressure To protect the airway against aspiration

c

What size endotracheal tube would you select to intubate an adult female? a. 6 mm 7 mm 8 mm 9 mm

c

When checking for proper placement of an endotracheal tube or a tracheostomy tube on a chest radiograph, how far above the carina should the distal tip of the tube be positioned? 1 to 2 cm 2 to 4 cm 3 to 6 cm 6 to 8 cm

c

Which of the following is likely to increase the likelihood of damage to the tracheal mucosa? Maintaining cuff pressures below 20 to 25 mm Hg Using the minimal leak technique for inflation Using a low-residual-volume, low-compliance cuff Monitoring intracuff pressures every 1 to 2 hr

c

Which of the following types of artificial airways are inserted through the larynx? 1. Pharyngeal airways 2. Tracheostomy tubes 3. Nasotracheal tubes 4. Orotracheal tubes 1 and 4 only 1, 2, and 3 only 3 and 4 only 1, 2, 3, and 4

c

While checking a crash cart for intubation equipment, you find the following: suction equipment, oxygen apparatus, two laryngoscopes and assorted blades, five tubes, Magill forceps, tape, lubricating gel, and local anesthetic. What is missing? 1. Obturator 2. Syringe(s) 3. Resuscitator bag and mask 4. Tube stylet 1, 2, and 3 only 2 and 4 only 2, 3, and 4 only 1, 3, and 4 only

c

You are about to suction a 10-year-old patient who has a 6-mm (internal diameter) endotracheal tube in place. What is the maximum size of catheter that you would use in this case? 6 Fr 8 Fr 10 Fr 14 Fr

c

A patient is being evaluated for tracheal damage sustained while having undergone prolonged tracheostomy intubation approximately 3 months earlier. The flow-volume loop demonstrates a fixed obstructive pattern. What is the most likely cause of the problem? Tracheomalacia Laryngeal web Cord paralysis Tracheal stenosis

d

A patient with a tracheal airway exhibits signs of tube obstruction. Which of the following are possible causes of this obstruction? 1. The tube cuff has herniated over the tip of the tube. 2. The tube is obstructed by a mucus plug or secretions. 3. The tube is kinked, or the patient is biting the tube. 4. The tube orifice is impinging on the tracheal wall. 2 and 4 only 3 and 4 only 1, 2, and 3 only 1, 2, 3, and 4

d

A surgical resident has asked that you assist in an elective tracheotomy procedure on an orally intubated patient. Which of the following would be an appropriate action? Remove the oral tube just before tracheostomy tube insertion. Remove the oral tube before the tracheotomy is performed. Pull the oral tube only after the tracheostomy tube is placed. Withdraw the oral tube 2 to 3 in while the incision is made.

d

Compared with the nasal route, the advantages of oral intubation include which of the following? 1. Reduced risk of kinking 2. Less retching and gagging 3. Easier suctioning 4. Less traumatic insertion 1 and 3 only 1, 2, and 3 only 1, 2, 3, and 4 1, 3, and 4 only

d

Compared with the oral route, the advantages of nasal intubation include which of the following? 1. Reduced risk of kinking 2. Less retching and gagging 3. Less accidental extubation 4. Greater long-term comfort 1 and 3 only 1, 2, and 3 only c. 3 and 4 only d. 2, 3, and 4 only

d

Immediately after insertion of an oral endotracheal tube on an adult, what should you do? 1. Stabilize it with your right hand. 2. Inflate the tube cuff. 3.Provide ventilation or oxygenation. 1 and 2 only 1 and 3 only 2 and 3 only 1, 2, and 3

d

Soon after endotracheal tube extubation, an adult patient exhibits a high-pitched inspiratory noise, heard without a stethoscope. Which of the following actions would you recommend? STAT-heated aerosol treatment with saline STAT racemic epinephrine aerosol treatment Careful observation of the patient for 6 hr Immediate reintubation via the nasal route

d

The major limitations of using a laryngeal mask airway are: 1. Short-term use. 2. Cannot provide high ventilation pressures if needed. 3. Aspiration not avoided. 1 and 2 only 2 and 3 only 1 and 3 only 1, 2, and 3

d

To make oral intubation easier, how should the patient's head and neck be positioned? Neck extended over the edge of the bed, with head dangling down Neck extended, with head supported by towel and flexed forward Both the neck and head fully extended, with neck supported by towel Neck flexed, with head supported by towel and tilted back

d

To minimize the problems associated with pharyngeal aspiration in intubated patients, which of the following could you recommend? 1. Position patients in prone position. 2. Use of medications for stress ulcer prophylaxis, such as sucralfate. 3. Positioning of patients with the head of the bed elevated 30 degrees. 4. Provide continuous aspiration of subglottic secretions. 1 and 2 only 2 and 4 only 1, 2, and 4 only 2, 3, and 4 only

d

Tracheal airways increase the incidence of pulmonary infections for which of the following reasons? 1. Lower levels of humidification 2. Increased aspiration of pharyngeal material 3. Contaminated equipment or solutions 4. Ineffective clearance through cough 1 and 3 only 1, 2, and 3 only 3 and 4 only 2, 3, and 4 only

d

Tracheal stenosis occurs in as many as 1 in 10 patients after prolonged tracheostomy. At what sites does this stenosis usually occur? 1. Cuff site 2. Tip of the tube 3. Stoma site 1 and 2 only 1 and 3 only 2 and 3 only 1, 2, and 3

d

What is a rare but serious complication associated with endotracheal tube extubation? a. Bradycardia b. Aspiration c. Infection d. Laryngospasm

d

What is the most common sign associated with the transient glottic edema or vocal cord inflammation that follows extubation? Difficulty in swallowing Wheezing Orthopnea Hoarseness

d

What is the purpose of the additional side port (Murphy eye) on most modern endotracheal tubes? Protect the airway against aspiration. Help ascertain proper tube position. Minimize mucosal trauma during insertion. Ensure gas flow if the main port is blocked.

d

Which of the following approaches may be used in "weaning" a patient from a tracheostomy tube? 1. Using progressively smaller tubes 2. Using a fenestrated tube 3. Using a tracheostomy button 1 and 2 only 1 and 3 only 2 and 3 only 1, 2, and 3

d

Which of the following bedside methods can absolutely confirm proper endotracheal tube position in the trachea? Auscultation Observation of chest movement Tube length (cm to teeth) Fiberoptic laryngoscopy

d

Which of the following factors should be considered when deciding to change from an endotracheal tube to a tracheostomy tube? 1. Patient's tolerance of the endotracheal tube 2. Relative risks of continued intubation versus tracheostomy 3. Patient's severity of illness and overall condition 4. Length of time that the patient will need an artificial airway 5. Patient's ability to tolerate a surgical procedure 1, 3, and 4 only 3, 4, and 5 only 2, 3, 4, and 5 only 1, 2, 3, 4, and 5

d

Which of the following is an advantage of oral intubation? Insertion is fast Esthetically displeasing Improved ability to swallow oral secretions Aids feeding, oral care, suctioning, speech

d

Which of the following is an indication for nasotracheal suctioning? Bronchospasm Hyperinflation Patient preference Retained secretions without artificial airway

d

Which of the following methods can help to reduce the likelihood of atelectasis due to tracheal suctioning? 1. Limit the amount of negative pressure used. 2. Hyperinflate the patient before and after the procedure. 3. Suction for as short a period of time as possible. 1 and 2 only 1 and 3 only 2 and 3 only 1, 2, and 3

d

Which of the following techniques may be used to diagnose injury associated with artificial airways? 1. Laryngoscopy or bronchoscopy 2. Physical examination 3. Air tomography 4. Pulmonary function studies 1 and 2 only 1 and 3 only 2, 3, and 4 only 1, 2, 3, and 4

d

Which of the following techniques or procedures should be used to help minimize infection of a tracheotomy stoma? 1. Regular aseptic stoma cleaning 2. Adherence to sterile techniques 3. Regular change of tracheostomy dressings 1 and 2 only 1 and 3 only 2 and 3 only 1, 2, and 3

d

You are about to suction a female patient who has an 8-mm (internal diameter) endotracheal tube in place. What is the maximum size of catheter you would use in this case? 8 Fr 10 Fr 12 Fr 14 Fr

d

You are assisting a physician in the emergency care of a patient with a maxillofacial injury who will require short-term ventilatory support. Which of the following airway approaches would you recommend? Intubate via the oral route. Insert an oropharyngeal airway. Perform an emergency tracheotomy. Intubate via the nasal route.

d