Module 13: Airway Management

A 73-year-old patient was admitted with severe respiratory distress secondary to pneumonia. She has a long history of smoking, which she recently stopped. On arrival she was placed on continuous pulse oximetry, and an endotracheal tube was inserted for mechanical ventilation. She is heavily sedated. She is receiving an intravenous infusion at 100 mL per hour. Intravenous fluids may affect this patient's respiratory status. A. True B. False

a Too little fluid can cause thickened secretions, and too much fluid may add stress to the heart. Monitor input and output closely. IV fluids can also help to keep her secretions thin and mobile.

What should the nurse do if patient's pulse goes from 60 to 100 beats per minute during closed inline suctioning? A. Stop suctioning and administer oxygen. B. Continue suctioning and administer oxygen.

a Correct A significant change in pulse rate indicates hypoxia. Stop suctioning and oxygenate the patient.

The patient s wife asks why the nurse turns the oxygen all the way up before suctioning the patient. What is the nurse s best response? A. Because suctioning will remove oxygen, the flow rate is increased to prevent a decrease in oxygen available to tissues. B. As secretions are removed, they need to be replaced with oxygen. C. A high concentration of oxygen stimulates the respiratory center so the patient will continue breathing during the suctioning procedure. D. It is necessary in order to create the pressure needed to make the suction machine work effectively.

a Correct Because suctioning removes oxygen, preoxygenation is required to prevent hypoxia. All other statements are inaccurate.

The nurse is performing endotracheal tube care. Which step is an appropriate nursing action for performing this skill? A. Use two people to carry out the procedure. B. Use the tongue blades to inspect the patient s oral cavity for sores. C. Fold the tape that holds the endotracheal tube in place lengthwise to prevent it from sticking to the patient's head or hair. D. Rotate the endotracheal tube to the opposite side of the mouth only if a lesion has developed under the tube.

a Correct Endotracheal tube care usually requires two people, one to perform the procedure and the other to hold the endotracheal tube in place during the procedure. Cut two pieces of tape, one approximately 2 feet long and the other approximately 1.5 feet long, and stick them to each other. The tongue blades are used to guide the endotracheal ties around the patient's head. The endotracheal tube should be rotated to the middle or opposite side of the mouth every 24 to 48 hours to prevent the development of skin breakdown.

Which situation can be delegated to nursing assistive personnel (NAP) in regard to endotracheal tube care? A. Assisting the nurse during a tape change by holding the endotracheal tube. B. Performing respiratory assessments before and after endotracheal tube care. C. Endotracheal care may be delegated to NAP only if the patient is on a ventilator. D. If the tapes are soiled, the NAP may change the tapes.

a Correct NAP can help with reporting signs that the tube is loose, the tapes are soiled, or the patient is uncomfortable and assisting in holding the tube during a tape change. Assessment requires the skill and knowledge of the nurse and should not be delegated to NAP.

The nurse is preparing to perform oropharyngeal suctioning. Which of the following steps in the sequence is incorrect? A. Assist the patient into a supine position. Prepare supplies. Turn the suction unit on and set the suction control gauge to high. Connect the suction tubing to the suction machine and to the Yankauer suction catheter. B. Place the suction catheter in the container of water and apply suction. If the patient has an oxygen device, remove it, placing it near the patient's face. Insert the catheter gently into the mouth along the gingival border (gum line). C. Gently move the catheter around the patient's mouth until all of the secretions are cleared. Encourage the patient to cough. Replace the oxygen mask. Suction water from the basin through the catheter until the catheter is cleared of secretions. Reassess the patient's respiratory status and repeat the procedure if necessary. D. Turn off the suction source. Wipe the patient's face. Discard the water into an appropriate receptacle. Discard the Yankauer suction catheter or place it in a nonairtight container to ensure that it remains uncontaminated. Provide oral care. Remove the gloves and perform hand hygiene. Record the procedure.

a Correct The nurse should place the patient in a Fowler's position, then perform hand hygiene, and finally set the suction control gauge according to manufacturer's directions. A high setting on the suction control gauge could cause damage to the oral mucosa. The other options are correct steps in the sequence for performing oropharyngeal suctioning.

Before performing endotracheal suctioning, the nurse presses the sigh mechanism on the mechanical ventilator. Why does the nurse do this? The nurse is: (Select all that apply.) A. preoxygenating the patient. B. offsetting the volume of oxygen lost during the suction procedure. C. compensating for the interruption in mechanical ventilation. D. preventing the development of atelectasis. The purpose of preoxygenating the patient, whether intubated or not, is to compensate for the loss of oxygen during the procedure.

a b c Before performing endotracheal suctioning, the nurse presses the sigh mechanism on the mechanical ventilator. Why does the nurse do this? The nurse is: (Select all that apply.) A. preoxygenating the patient. Correct B. offsetting the volume of oxygen lost during the suction procedure. Correct C. compensating for the interruption in mechanical ventilation. Correct D. preventing the development of atelectasis. Incorrect The purpose of preoxygenating the patient, whether intubated or not, is to compensate for the loss of oxygen during the procedure.

Which of the following statements regarding nasotracheal suctioning are true? (Select all that apply.) A. The suction catheter should be rotated as it is withdrawn. B. Sterile technique is required. C. Suction should be applied intermittently as the catheter is removed. D. Clean technique may be used. E. This procedure can be delegated to NAP.

a b c Sterile technique is required for nasotracheal suctioning to prevent introducing microorganisms into the trachea. Suction is applied intermittently and the catheter is rotated as it is removed to prevent adherence of the mucosa to the suction catheter and to facilitate removal of secretions. Nasotracheal suctioning should not be delegated to NAP. NAP may perform oropharygeal suctioning where clean technique is used.

The nurse is caring for a patient who underwent major abdominal surgery 24 hours ago. The 72-year-old male patient is weak and lethargic because of large doses of medication for pain control. After noting audible gurgling on inspiration and expiration, the nurse completes a respiratory assessment. Which assessment parameters indicate the need for oral suction? (Select all that apply.) A. Gurgling and adventitious lung sounds. Correct B. Gagging. Correct C. Unusual restlessness. Correct D. Evidence of emesis in the mouth. Correct E. Persistent complaints of pain. F. Persistent coughing that fails to clear airway. Correct G. Weakness and lethargy accompanied by drooling. Correct

a b c d f g The following signs indicate the need for oropharyngeal suctioning: (1) restlessness, especially if it is new or unusual for the patient; (2) obvious, excessive oral secretions as evidenced by drooling and/or gagging; (3) gurgling and/or audible crackles and wheezes that occur on inspiration and/or expiration; (4) evidence of gastric contents and/or emesis in the mouth; (5) persistent coughing that fails to clear the upper airway; and (6) weakness and lethargy accompanied by drooling and gagging. Persistent complaints of pain are more likely related to the surgery.

You are reviewing the signs, symptoms, and prevention of hypoxia with the family of a patient who requires frequent suctioning at home. Choose the information that you should cover. (Select all that apply.) A. Restlessness and anxiety are indications of hypoxia. B. Increases in pulse, respiration, and blood pressure are indications of hypoxia. C. Confusion, disorientation, and altered consciousness are indications of hypoxia. D. Bronchitis and chronic obstructive pulmonary disease are indications of hypoxia. E. Having difficulty breathing and looking blue are indications of hypoxia. F. Infection and fever are indications of hypoxia.

a b c e Indications of hypoxia include restlessness, anxiety, confusion, disorientation, and altered consciousness as well as increases in pulse rate, respiration rate, and blood pressure. Feeling out of breathe and looking blue also indicate hypoxia.

Choose the symptoms that indicate the need to suction a tracheostomy tube. (Select all that apply.) A. Mucus draining from the tracheostomy tube. B. Sonorous wheezing. C. Cyanosis. D. Posturing. E. Restless/anxious. F. Gurgling. G. Pulse oximetry value less than 90%. H. Fatigue.

a b c e f g Signs and symptoms that indicate that a tracheostomy may need suctioning include coughing, wheezes, gurgling, crackles on inspiration and/or expiration, restlessness/anxiety, cyanosis, mucus draining from the tracheostomy tube, and pulse oximetry values less than 90%. Suctioning would further increase fatigue. Posturing may be seen with brain injury.

The nurse is preparing to perform nasotracheal suctioning on a patient. Which of the following actions would indicate a break in sterile technique? (Select all that apply.) A. The nurse uses the same suction catheter to suction the oral cavity followed by the endotracheal tube and then discards the suction catheter inside the gloves into an appropriate receptacle. B. The nurse picks up the catheter with the dominant hand, then picks up the connecting tubing with the nondominant hand and secures the catheter to the tubing. C. As the nurse places the sterile basin on the bedside table, the nurse touches the inside of the basin with the nonsterile glove. D. The nurse applies a sterile glove to the dominant hand and a nonsterile glove to the nondominant hand.

a c The nurse should avoid touching the inside of the sterile basin with the nonsterile glove because this would contaminate the sterile basin. The nurse should not use the same suction catheter to suction the mouth and then the trachea because this would introduce microorganisms into the trachea. The nurse may suction the trachea first, followed by the oral route using the same catheter.

Identify the situations that require endotracheal tube care. (Select all that apply.) A. Soiled or loose tape. B. Patient was recently shaved. C. Pressure sore on naris or corner of mouth. D. Foul odor of mouth. E. Breath sounds are equal and endotracheal tube remains at same depth.

a c d Signs and symptoms of the need to perform endotracheal tube care include the following: soiled or loose tape; a pressure sore on the naris, lips, or corner of the mouth; excess nasal or oral secretions; patient moving the tube with the tongue or biting the tube or tongue; tube repositioned by the physician or other specially trained personnel; and foul-smelling mouth. The endotracheal tube should remain at the same depth when breath sounds are equal. Shaving a male patient may be performed during endotracheal tube care.

An elderly woman is hospitalized with pneumonia and anemia and has a history of heart failure. She is weak and has a poor cough effort. Her current vital signs are temperature 100.2 °F (37.9 °C), pulse 114, respiration 26, blood pressure 106/58. She has oxygen ordered at 2 liters by nasal cannula. Her oxygen saturation measures 88% when on room air, 93% with supplemental oxygen. She develops shortness of breath on any activity and eats little because it is difficult for her to eat and breathe at the same time. Which of the following are risk factors for this patient developing hypoxia? (Select all that apply.) A. Increased secretions with weak cough. B. Shortness of breath. C. Pneumonia. D. Impaired cardiac function. E. Tachycardia. F. Anemia.

a c d f Hypoxia results when there is inadequate tissue oxygenation at the cellular level. Lowered oxygen-carrying capacity from anemia can lead to hypoxia. A diminished concentration of inspired oxygen, such as with an obstructed airway from secretions, results in lowered oxygen saturation. Impaired cardiac function results in poor tissue perfusion with oxygenated blood. With pneumonia there is decreased diffusion of oxygen from the alveoli to the blood, leading to inadequate tissue oxygenation. An increase in pulse rate is an adaptive response to meet the body's oxygen demand. Shortness of breath (dyspnea) is a symptom of decreased oxygenation.

The nurse is preparing to perform routine tracheostomy care. Which statements, if made by the nurse, indicate that further instruction is needed? (Select all that apply.) A. "After I clean the inner cannula and replace it, I may use the brush to clean around the stoma." B. "I will drop the inner cannula into a sterile basin of normal saline." C. "After I secure the ends of the tracheostomy ties, I should be able to fit one finger loosely or two fingers snugly under the ties." D. "I should clean the tracheostomy stoma in a circular motion from the stoma site moving outward approximately 2 to 4 inches." E. "I will double knot the ties behind the patient's neck."

a e The inner cannula should be dropped into the sterile basin of normal saline for cleaning, or if disposable, the inner cannula would be discarded. The ties should be secured in a double square knot on the side of the neck. One finger of slack prevents the ties from being too tight and also prevents movement of the tracheostomy tube. The stoma site should be cleaned to remove secretions. Moving in an outward circle pulls mucus and other contaminants away from the stoma to the periphery. The tracheostomy brush is used to remove thick or dried secretions from the cannula. It would be too harsh and contaminated to use on the peristomal skin. Sterile 4- ✕ 4-inch gauze is used to clean around the stoma.

A 73-year-old patient was admitted with severe respiratory distress secondary to pneumonia. She has a long history of smoking, which she recently stopped. On arrival she was placed on continuous pulse oximetry, and an endotracheal tube was inserted for mechanical ventilation. She is heavily sedated. This patient's risk factors for respiratory problems include history of smoking, her illness, and her age. A. True B. False

b She was a smoker for many years, and her age and illness place her at greater risk for respiratory distress.

For a patient with an endotracheal tube on mechanical ventilation, preoxygenation is unnecessary before suctioning because the ventilator will maintain the patient's oxygen levels. A. True B. False

b The ventilator should be set to deliver 100% oxygen before suctioning this patient.

Which of the following patients is most likely to experience some difficulty with effective coughing? A. The elderly patient who had outpatient foot surgery. B. The patient who is postoperative for abdominal surgery. C. The middle-age man who is postoperative for knee arthroplasty. D. The patient who preoperatively practiced cascade coughing.

b Correct Abdominal surgery causes pain and weakness of the abdominal muscles, both of which can result in ineffective airway clearance. Learning coughing techniques preoperatively will aid in postoperative performance of these skills.

The nurse is performing routine assessments of the patients on the unit. The nurse notes audible gurgling on inspiration and expiration of the stable postoperative patient. Which of the following tasks can be delegated to competent NAP? A. Performing nasotracheal suctioning. B. Performing oral suctioning. C. Assessing the adequacy of respiratory functioning. D. Evaluating the outcome of oral suctioning.

b Correct Because the patient is stable, the task of performing oral suctioning may be delegated to NAP. However, the responsibility for assessing the adequacy of respiratory functioning and evaluating the patient outcome of oral suctioning remains with you. Nasotracheal suctioning requires sterile technique and cannot be delegated to NAP.

In retrospect, the student nurse realizes that he failed to hyperoxygenate the patient before the procedure. What is the risk for the patient? A. Infection. B. Hypoxia. C. Increased discomfort. D. Thickened secretions.

b Correct Even if the patient is on room air, he or she is at risk for developing hypoxia. Hyperoxygenating the patient will help prevent this occurrence.

What is the purpose of having a fenestrated tube in an artificial airway? A. To decrease the likelihood of aspiration of stomach contents. B. To allow a patient to talk. C. To prevent dislodgment. D. To prevent trauma to the trachea.

b Correct Fenestrations allow air to pass over the vocal cords, enabling the patient to talk. The inflated cuff helps decrease the likelihood of dislodgment. Endotracheal tubes are nonfenestrated so that the trachea remains trauma free.

A patient has an endotracheal tube inserted orally. When should the nurse expect to perform endotracheal tube care? A. Whenever the patient begins to cough. B. On a routine schedule according to agency policy to reposition the tube. C. Only when the depth of the tube has changed from its original position (as indicated by a marking at the lip or gum line). D. According to health care provider orders.

b Correct If endotracheal tube is inserted orally, the tube is often repositioned on the opposite side of the mouth or center of mouth according to agency protocol to prevent prolonged pressure and ulceration. Endotracheal tube care is usually performed on a routine schedule. Coughing, especially continued coughing, usually indicates a need for more frequent suctioning. Endotracheal tube care is indicated if the depth of the tube has changed.

The nurse is orienting a new graduate nurse to common procedures performed on the unit. Which statement, if made by the graduate nurse, indicates understanding of nasotracheal suctioning? A. "The bacterial count in the nasotracheal pathway is higher, therefore suction the trachea through the mouth." B. "A 1- to 2- minute interval should be allowed between suctioning passes." C. "The maximum duration to suction is 20 seconds." D. "Intermittent suction is applied during insertion of the catheter."

b Correct Intermittent suction up to 15 seconds safely removes pharyngeal secretions. The maximum time to suction the trachea is 10 seconds, with a 1- to 2-minute interval in between suctioning passes for reoxygenation. The mouth carries the highest bacterial count. Whenever possible, suction via the nasotracheal route. To avoid tissue damage, intermittent suction is applied as the catheter is being withdrawn.

Which of the following is an inaccurate statement in regard to performing endotracheal tube care? A. To secure the tapes around the tube, place the top side of the torn tape across the patient's upper lip and tightly wrap the lower side around the tube. B. When rotating the endotracheal tube from one side of the mouth to the other, deflate the cuff. C. Cut first piece of tape approximately 1 to 2 feet (24 to 48 cm) in length; lay adhesive-side up on table. D. Have assistant hold tube in place and note the markings on the tube indicating depth of tube insertion before removing old tape or tube holder.

b Correct Never deflate the cuff during tube rotation. This could potentially dislodge the tube.

A 73-year-old patient was admitted with severe respiratory distress secondary to pneumonia. She has a long history of smoking, which she recently stopped. On arrival she was placed on continuous pulse oximetry, and an endotracheal tube was inserted for mechanical ventilation. She is heavily sedated. This patient is at risk for airway occlusion. A. False B. True

b Correct She must constantly be monitored for airway occlusion.

The nurse is performing closed inline suctioning. Preprocedure assessment indicated crackles and wheezes bilaterally, pulse rate 72, respiratory rate 20 breaths per minute, and pulse oximetry 89%. Which of the following indicates the nurse should stop suctioning and administer oxygen? A. The patient's respiratory rate remains unchanged. B. The patient's pulse increases to 114 beats per minute. C. The patient's pulse oximetry increases to 94%. D. Thick clear sputum is obtained during suctioning.

b Correct Stop suctioning if the patient's pulse increases or decreases by 20 beats per minute or if the oxygen saturation falls below 90% or 5% below baseline. Secretions should be obtained with suctioning to help improve the patency of the patient's airway. As secretions are removed and the airway is cleared, the patient's oxygen saturation should show improvement.

Which of the following can be removed for cleaning, especially if the patient has copious or tenacious secretions? A. The flange. B. The inner cannula of the tracheostomy tube. C. The obturator. D. The outer cannula of the tracheostomy tube.

b Correct The inner cannula may be removed and cleaned, or if disposable, discarded and replaced. The outer cannula should never be removed. Removal of the outer cannula would cause the tracheostomy tract to close, and in turn this would close the patient's airway. The obturator is a stylet used for initial insertion of the tracheostomy tube and is then removed to allow for airflow. The area under the flange, as well as the flange itself, is cleaned but not removed because it aids in securing the entire system to the patient's neck.

1. A patient may go home with a tracheostomy tube. Before discharge, the patient and the patient's family should be taught all of the following routine tracheostomy tube care measures except: A. Expected drainage from the tracheostomy and when to notify the health care provider. B. How to remove the tracheostomy tube. C. How to suction the tracheostomy tube. D. Recognizing signs and symptoms of hypoxia and how to prevent hypoxia.

b Correct The patient and/or the patient's family should not remove the tracheostomy tube as this may result in closure of the patient's airway. Only the inner cannula should be removed for cleaning. The patient and the patient's family should be taught tracheostomy care, including suctioning, cleaning, replacing the ties, and recognizing the signs and symptoms of hypoxia and infection so they may take corrective action or seek additional medical care.

The nurse desires to suction the patient's left main-stem bronchus. In what position should the patient be placed? A. Turn the patient's head to the left. B. Turn the patient's head to the right. C. Keep the patient's head in a neutral position and rotate the catheter counter-clockwise on insertion. D. Keep the patient's head in a neutral position and rotate the catheter clockwise on insertion.

b Correct To effectively suction the left main-stem bronchus, turn the patient's head to the right.

Which of the following is a potential complication for a patient who is having nasotracheal suctioning? (Select all that apply.) A. Coughing during and after suctioning B. A significant drop in oxygen concentration. C. A decrease in heart rate. D. Dysrythmias. E. Less secretions in the airway.

b c d The patient is at risk for developing hypoxemia at any point from assessment of airway secretions to a short time after the suctioning procedure. The suctioning procedure itself removes oxygen from the airways. A patient may experience bradycardia as a result of vagal stimulation. Dysrhythmias are a potential complication of nasotracheal suctioning. Coughing is an expected outcome of nasotracheal suctioning and will aid in clearing the airways.

The nurse is preparing to perform tracheal suctioning on a patient. Which of the following would be an appropriate nursing action? Select all that apply. A. To effectively suction the left main stem bronchus, turn the patient's head to the left. B. Hyperoxygenate patient with artifical airway before suctioning. C. When suctioning artificial airways, apply suction during insertion. D. For open nasotracheal suctioning, clean gloves are appropriate. E. Allow at least 1 full minute between suction passes.

b e To reduce the likelihood of hypoxia, the nurse should hyperventilate the patient before suctioning and allow 1 to 2 minutes between suction passes. To effectively suction the left main-stem bronchus, turn the patient's head to the right. Never apply suction during insertion because you could damage the mucosa of the trachea. Sterile gloves and aseptic technique are required for nasotracheal suctioning.

The nurse was changing the patient's tube holder on his endotracheal tube when he reached up and extubated himself. What actions should the nurse take? (Select all that apply.) A. Run and get help. B. Administer breaths with an Ambu-bag self-inflating resuscitation bag if necessary. C. Put the endotracheal tube back in. D. Apply sterile gloves. E. Remain with the patient and use the call system to obtain assistance. F. Perform oropharyngeal suctioning. G. Put a tongue blade in the patient's mouth. H. Assess the patient for spontaneous breathing.

b e h Correct nursing actions for unexpected extubation include the following: remain with the patient; call for assistance; assess the patient for airway patency, spontaneous breathing, and vital signs (including oxygen saturation); and prepare for reintubation by the health care provider, administering breaths with an self-inflating resuscitation bag in the meantime.

What nursing intervention is appropriate for the patient with a large amount of sputum? A. Perform nasotracheal suctioning every hour. B. Place the patient on fluid restriction. C. Encourage the patient to cough every hour while awake. D. Avoid all milk products.

c Correct A patient with a large amount of sputum should be encouraged to cough every hour while awake. Adequate fluids should be maintained to help keep secretions thin and easier to expectorate. Although milk has a protein structure similar to sputum, it does not increase sputum production and plays an important role in nutrition. Suctioning should be performed on an as-needed basis.

1. Which of the following should NOT be delegated to nursing assistive personnel (NAP)? A. Oropharyngeal suctioning. B. Oral care. C. Nasotracheal suctioning. D. Pulse oximetry.

c Correct Because sterile technique and critical thinking skills are required, it is inappropriate to delegate nasotracheal suctioning to NAP. The other tasks can be performed by NAP on stable patients.

Which of the following patients should be assessed for a worsening clinical situation? A. The patient who demonstrates less drooling after being suctioned. B. The patient with absence of adventitious lung sounds on inspiration and expiration. C. The patient with presence of blood in the secretions. D. The chronic obstructive pulmonary disease (COPD) patient whose pulse oximetry remains the same after oropharyngeal suctioning.

c Correct Bloody secretions are an unexpected outcome. The cause should be investigated. The removal of secretions helps to improve the oxygen saturation level. In patients with chronic pulmonary diseases such as COPD, the pulse oximetry value may remain the same. The absence of adventitious sounds is an expected finding. An expected outcome of oropharyngeal suctioning is lessened or absence of drooling.

Which of the following would lead to an increase in oxygen demand? A. Postural drainage. B. Taking a narcotic. C. A fever. D. Sleep.

c Correct Increased metabolic activity associated with a fever increases tissue oxygen demand. Postural drainage is an intervention used to mobilize secretions and maintain an open airway.

A discussion is taking place on the unit regarding the application of lubricant to the suction catheter before passing it through the nasal passage. Which statement is accurate? A. "Applying water-soluble lubricant to the suction catheter ensures that it is working properly prior to oropharyngeal or nasotracheal suctioning." B. "Petroleum jelly can be used to lubricate the catheter as long as the patient is not on oxygen via nasal cannula." C. "Water-soluble lubricant should be used because oil based lubricants increase the risk for aspiration and pneumonia." D. "If the patient's fluid status is sufficient, lubricating the catheter is unnecessary."

c Correct Oil-based lubricants increase the risk for aspiration and pneumonia. Water-soluble lubricant is applied to the catheter to ease insertion and prevent tissue trauma. It is unrelated to the patient's fluid status. Suctioning a small amount of sterile normal saline from the basin ensures that the suction system is working correctly. It is unnecessary to lubricate the end of the suction catheter when performing oropharyngeal suctioning.

Which of the following, if exhibited by the patient, is a late sign of hypoxia? A. Anxiety. B. Eupnea. C. Cyanosis. D. Restlessness.

c Correct Restlessness and anxiety are early indicators of hypoxia. Cyanosis is a late indicator of hypoxia. Eupnea is normal respiration.

The nurse is teaching the spouse of a patient how to perform oral suctioning for when they return home. Which of the following statements, if made by the spouse, indicates further instruction is needed? A. "I should encourage fluids to help keep secretions thin." B. "I should be careful to avoid touching the back of the throat with the tip of the suction catheter." C. "Because oral secretions are thick, suction settings should always be set on high." D. "It would be abnormal to obtain bloody secretions."

c Correct Suction settings should be low to ensure that the oral tissue is uninjured during suctioning. Bloody secretions may be an indication of mucosal damage. The oropharynx should be assessed for any tissue injury, and the frequency of suctioning should be evaluated. Touching the back of the throat can stimulate the gag reflex. Unless contraindicated, fluids should be encouraged to reduce the viscosity of secretions.

Which of the following would be an appropriate nursing diagnosis for the patient who has a tracheostomy tube? A. Risk of fluid volume excess. B. Fluid volume deficit. C. Risk of impaired skin integrity. D. Impaired mobility.

c Correct The nurse must be alert to the development of skin irritation below the tracheostomy flange and around the site of insertion. Impaired mobility, fluid volume deficit, and risk of fluid volume excess are not related to the presence of a tracheostomy tube. The nurse must be alert for defining characteristics of other nursing diagnoses, including impaired airway clearance, infection, pain, or altered skin integrity.

For the patient who extubated himself, what priority action should the nurse take? A. Apply a sterile dressing to the site. B. Medicate the patient for pain and assess for tissue damage. C. Determine whether the patient is breathing spontaneously. D. Notify the health care provider.

c Correct The nurse should stay with the patient, determine if the patient is breathing spontaneously, and assist respirations as needed with an Ambu-bag. All other actions are not priority actions.

The nurse is going to perform inline tracheostomy suctioning followed by tracheostomy tube care (using a disposable inner cannula). Which of the following is an incorrect step in the sequence for these procedures? A. Cut existing tracheostomy ties and remove them. Install new tracheostomy ties. Insert new tracheostomy dressing. Discard used equipment and supplies. Reposition patient. B. Remove existing tracheostomy dressing and discard gloves. Perform hand hygiene. Using sterile technique, open tracheostomy kit. Prepare supplies: open 4- ✕ 4-inch gauze, saline; pour saline solution over cotton swabs. Open tracheostomy dressing package, prepare fixation device, open new inner cannula. C. Apply clean gloves. Remove existing inner cannula. Clean around stoma and flange with brush in outward circle moving toward stoma. Insert new inner cannula. Have assistant hold tracheostomy tube. D. Apply suction. Withdraw catheter to the point indicated. Lock suction catheter. Turn off suction machine. Provide oral care. E. Perform hand hygiene. Connect suctioning tubing to suction machine. Set on low. Hyperoxygenate patient. Unlock suction catheter. Insert catheter during inspiration.

c Correct The nurse should wear sterile gloves. The assistant should be stabilizing the TT for removal of the inner cannula and during TT care. The nurse should remove inner cannula and replace with new inner cannula, locking it into position. The nurse should clean around the stoma and flange using the sterile cotton swabs and 4 X 4-inch gauze in circular motion from stoma outward; pat dry with sterile gauze. All other steps are correctly performed.

1. Which of the following patients may likely require oropharyngeal suctioning? (Select all that apply.) A. A patient who has been diagnosed with lung cancer. B. A patient who has a nasogastric feeding tube. C. A patient with an artificial airway who requires oral hygiene. D. A patient who had trauma to the mouth. E. A patient with impaired swallowing from neurological injury. F. A patient who had maxillofacial surgery.

c d e f The Yankauer suction device is useful in the removal of secretions from the mouth in patients after oral and maxillofacial surgery, trauma to the mouth, neurovascular injury and/or cerebrovascular accident causing hemiparesis and drooling, or impaired swallowing. Patients with artificial airways and impaired swallowing ability may require use of the Yankauer suction device to promote oral hygiene. Patients with lung cancer or pneumonia may be able to cough up or swallow secretions on their own.

1. Which task(s) could be delegated to trained nursing assistive personnel (NAP)? Select all that apply. A. Closed inline suctioning if a patient is on a mechanical ventilator. B. Nasotracheal suctioning. C. Oropharyngeal suctioning. D. Endotracheal tube care. E. Tracheostomy care of a well-established tracheostomy.

c e The patient, patient's family, and NAP may be trained in tracheostomy care of a well-established tracheostomy. The NAP may be assigned oropharyngeal suctioning. Nasotracheal suctioning and closed inline suctioning are beyond the scope of NAP. The NAP may assist the nurse in performing endotracheal care, but the task should not be delegated to NAP.

What happens if the inline suction device is locked? A. It should be locked to clear secretions from the catheter. B. Suction will occur. C. Suction will occur continuously until you turn it off. D. Nothing; you cannot apply suction.

d *a. In the locked position, you cannot apply suction. b. If the device is locked, nothing occurs. This is a safety feature. c. The lock is a safety feature that prevents suctioning from occurring. d. In the locked position you would be unable to apply suction to clear the secretions. The locked position is a safety feature that prevents suctioning from occuring.

After the NAP performs routine vital signs on the patient, the NAP reports to the nurse that the patient is restless, and it sounds like the patient is gurgling. Vital sign readings indicate a pulse of 72, respiratory rate of 20 breaths per minute, and a pulse oximetry of 89%. What is the most appropriate action at this time? A. Consult with the health care provider regarding need for a bronchodilator. B. Document the normal findings. C. Have the patient take a deep breath and reassess pulse oximetry. D. Suction the patient s airway.

d Correct A pulse oximetry reading of 89% is not considered within normal limits. Restless behavior, audible gurgling, and a pulse oximetry of 89% are indications the patient requires suctioning. The patient needs to have secretions removed in order to improve the pulse oximetry reading. A bronchodilator may be requested if no secretions are obtained with suctioning.

A nurse is trying to determine whether or not a patient's artificial airway should be suctioned. Which of the following is not an indication for suctioning? A. Two hours have elapsed since patient was last suctioned. B. Patient has audible gurgling and appears restless. C. Pulmonary secretions. D. Pulse oximetry 89%.

d Correct A pulse oximetry reading of less than 90% indicates a low oxygen level. Suctioning removes secretions that are partially occluding the airway, and once these are removed, there should be increased oxygen delivery. Patients should be suctioned as needed, not according to a time schedule, because frequent unnecessary suctioning may cause airway irritation (bloody secretions) and patient discomfort.

1. Which of the following patients would have the greatest potential for an alteration in respiration? A. A 32-year-old man with an earache. B. A 15-year-old boy with a migraine headache. C. A 19-year-old woman with diarrhea. D. A 44-year-old woman with anemia.

d Correct Hemoglobin carries about 97% of oxygen to the tissues. Anemia lowers the oxygen-carrying capacity of the blood and potentially leads to hypoxia.

1. The nurse is caring for a patient who has an endotracheal tube inserted orally. The nurse instructs the NAP to report if the patient indicates signs of pain. Because the patient cannot communicate verbally, what signs of pain should the NAP report? A. Ability of the patient to move the tube with the tongue or to bite down on the tube. B. Coughing or audible gurgling. C. Foul-smelling breath or remaining secretions in the mouth. D. Increased restlessness or a sudden change in vital signs.

d Correct Increased restlessness, inability to sleep, crying, and a sudden change in vital signs are all indicators of pain in the nonverbal patient. Coughing or audible gurgling, foul-smelling breath, or remaining secretions in the mouth indicate the patient may require suctioning but are not a sign of pain. If the patient is able to move the tub with his tongue or bite down on it, the tube may need to be resecured

The nurse is orienting a newly hired nurse to a surgical intensive care unit. The newly hired nurse asks when endotracheal tube care is necessary. What is the correct response? A. "It should be done at least every 8 to 12 hours." B. "When the patient begins to cough continuously." C. "Indications for endotracheal tube care include wheezes, crackles, audible gurgling, secretions in the mouth, decreased pulse oximetry, tachypnea, and tachycardia." D. "Signs that endotracheal tube care must be performed include loosening of the tapes, soiled tapes, mobility of the tube, and alteration in skin or tissue integrity."

d Correct Signs that endotracheal tube care must be performed include loosening of the tapes, soiled tapes, mobility of the tube, and alteration in skin or tissue integrity. Continuous coughing may indicate that the patient needs suctioning. Tracheostomy tube care is performed every 8 to 12 hours or according to agency policy. The patient with an endotracheal tube is assessed at least once a shift for the need for endotracheal tube care. Wheezes, crackles, audible gurgling, secretions in the mouth, decreased pulse oximetry, tachypnea, and tachycardia are all indications that the patient needs suctioning.

During clinical postconference, a student nurse is telling the group about his day in the intensive care unit (ICU). He says that he was performing inline suctioning when the patient's pulse oximetry reading changed from 96% to 90% and the patient's heart rate went from 86 to 62 beats per minute. What action should the student nurse report having taken? A. Nothing, because this is an expected finding while suctioning. B. Reassure the patient and request that she cough. C. Withdraw the suction catheter. D. Stop suctioning and administer oxygen.

d Correct Suctioning should be stopped if the patient's pulse rate increases or decreases by 20 beats per minute, or if the oxygen saturation falls below 90% or 5% below baseline

A patient has clear oral secretions that are extremely copious and thick. What would be an appropriate response by the nurse? A. Nasotracheal suctioning. B. Obtain a sputum specimen for culture and sensitivity. C. Nasopharyngeal suctioning. D. Oropharyngeal suctioning.

d Correct The Yankauer suction catheter, used with oropharyngeal suctioning, is angled to facilitate removal of pharyngeal secretions through the mouth. This catheter is used instead of a standard suction catheter when oral secretions are extremely copious and thick because it can handle large volumes of secretions better than a standard suction catheter. The sputum is clear, which indicates absence of infection; furthermore, a physician's order would be required for this lab test.

The nurse performs nasotracheal suctioning. Which of the following is an incorrect sequence for this procedure? A. Using dominant hand, gently but quickly insert the catheter into the patient's nares and intermittently suction and rotate the catheter while withdrawing the catheter. B. Wearing sterile gloves, suction a small amount of sterile normal saline from the basin and lightly coat 6 to 8 cm of the catheter with water-soluble lubricant. C. Rinse the catheter and connecting tubing with normal saline and allow the patient to rest 1 to 2 minutes between catheter passes. Encourage the patient to cough, and when suctioning is complete, appropriately discard used equipment and perform oral care. D. Apply sterile gloves, pick up the suction catheter with dominant hand, secure the catheter to the tubing, connect the tubing to the suction machine, and turn the suction on.

d Correct The connecting tubing should be attached to the suction machine and turned on before applying sterile gloves.

Which of the following is an unexpected outcome during or after endotracheal suctioning and endotracheal tube care? A. Bilateral breath sounds are equal. B. Clean tape is firmly secured to cheeks, upper lip, top of nose, and tube only. C. Depth of tube is the same as when started or as ordered (same centimeter marking at gums or lips). D. A sudden drop in oxygen saturation.

d Correct The nurse should stop suctioning and administer oxygen. The other items are expected outcomes of performing endotracheal tube care.

Which step in the sequence of nasopharyngeal suctioning requires correction? A. Perform hand hygiene. Connect suction tubing to the suction machine and turn it on. Have supplemental oxygen available. B. Apply sterile gloves. Attach suction catheter to connecting tubing. Test the assembled suctioning equipment. C. Maintaining sterile technique, open suction catheter. Fill the basin with 100 mL of sterile saline/water. Open the package of water-soluble lubricant. D. Lubricate the end of the catheter. Insert the catheter during expiration. Apply continuous suction for approximately 1 minute as the catheter is withdrawn.

d Correct The suction catheter should be inserted during inhalation, and intermittent suction should be applied for 10 seconds. Continuous suctioning for a minute may cause tissue damage. All other steps are appropriate.

A patient with a weak cough has secretions in the lower airway. What would be an appropriate response by the nurse? A. Quad cough. B. Nasopharyngeal suctioning. C. Oropharyngeal suctioning. D. Nasotracheal suctioning.

d Correct This patient requires suctioning. Nasotracheal suctioning is used to remove secretions from the lower airways and requires aseptic technique. Oropharyngeal suctioning is used to clear pharyngeal secretions. Nasopharyngeal suctioning is used to remove secretions from the posterior oral cavity. The quad cough technique is used for patients without abdominal muscle control, such as those with spinal cord injuries.

The student nurse is observing the staff nurse perform routine tracheostomy care. Which of the following actions, if made by the staff nurse, would be inappropriate? A. The nurse removes the inner cannula and places it in a sterile basin of normal saline. B. The nurse oxygenates the patient, suctions the tracheostomy tube, and removes the soiled tracheostomy dressing before removing gloves. C. The nurse cleans around the tracheostomy faceplate and stoma with normal saline-saturated sterile cotton-tipped applicators and sterile gauze. D. The nurse removes the soiled tracheostomy ties, cleans the flange, and applies new tracheostomy ties, securing them tightly behind the patient's neck.

d Correct Unless an assistant is holding the tracheostomy tube in place, the nurse should not cut the soiled ties until the new tracheostomy ties are firmly tied. The knot of the ties should not be placed behind the patient's neck, and there should be enough room to fit one finger loosely or two fingers snugly under the ties. All other options are appropriate actions.