NUR211 Exam 3 airway management, oxygenation, & Performing Chest Physiotherapy

The client is admitted to the emergency department with a pneumothorax. The nurse anticipates that the client will be experiencing: 1. Dyspnea 2. Eupnea 3. Fremitus 4. Orthopnea

ANS: 1 The client with a pneumothorax (collapsed lung) will exhibit dyspnea and pain. Eupnea is normal, easy breathing. It would not be expected in the case of a pneumothorax. Fremitus is the vibration felt when the hand is placed on the client's chest and the client speaks (vocal fremitus). Fremitus would be decreased with a pneumothorax. Orthopnea is a condition in which the person must use multiple pillows when lying down or must sit with the arms elevated and leaning forward to breathe. The client with a pneumothorax would be exhibiting dyspnea.

Several nursing students are discussing cardiac conduction with their clinical instructor. When asked where a heart rate of 56 beats per minute most likely originates, the most informed student replies: 1. The atrioventricular (AV) node 2. The sinoatrial (SA) node 3. The Purkinje network 4. The bundle of His

ANS: 1 The conduction system originates with the sinoatrial (SA) node, the "pacemaker" of the heart. The SA node is in the right atrium next to the entrance of the superior vena cava. Impulses are initiated at the SA node at an intrinsic rate between 60 and 100 beats per minute. The electrical impulses are transmitted through the atria along intraatrial pathways to the atrioventricular (AV) node. The AV node mediates impulses between the atria and the ventricles. The intrinsic rate of the normal AV node is between 40 and 60 beats per minute. The AV node assists atrial emptying by delaying the impulse before transmitting it through the bundle of His and the ventricular Purkinje network. The intrinsic rate of the bundle of His and the ventricular Purkinje network is between 20 and 40 beats per minute.

A client with coronary artery disease is being prepared for a coronary arterial bypass graft surgery. The nurse knows that the coronary artery that carries the most blood and can cause the most harm when blocked is the: 1. Left coronary artery 2. Posterior interventricular artery 3. Circumflex artery 4. Anterior interventricular artery

ANS: 1 The left coronary artery, the most abundant blood supply, feeds the left ventricular myocardium, which is more muscular and does most of the heart's work. The posterior and anterior interventricular arteries supply blood to the walls of both ventricles. The circumflex artery supplies blood to the walls of the left atrium and left ventricle

When the nurse is reviewing a client's laboratory results, a low calcium level is noted. When the nurse then reviews the client's electrocardiogram, the most likely change noted will be a(n): 1. Increased Q-T interval 2. Increased P-R interval 3. Q-T interval less than 0.12 seconds 4. QRS interval greater than 0.12 seconds

ANS: 1 The normal Q-T interval is 0.12 to 0.42 second. Changes in electrolyte values, such as hypocalcemia, or therapy with drugs such as disopyramide or amiodarone increase the Q-T interval. The remaining options do not reflect a low calcium level.

When obtaining vital signs, a nursing assistive personnel is concerned that the heart rate of 56 is too low for a 23-year-old client who has been training for a marathon. The nurse explains that: 1. A low heart rate is normal in well-conditioned athletes 2. The health care provider needs to be notified immediately 3. The heart rate needs to be rechecked before taking any action 4. The heart rate could be caused by hyperthyroidism

ANS: 1 A heart rate lower then 60 is a normal response to sleep or in a well-conditioned athlete; diminished blood flow to SA node, vagal stimulation, hypothyroidism, increased intracranial pressure, or pharmacological agents (e.g., digoxin, propranolol, quinidine, procainamide) sometimes cause abnormal drops in rate. Any action that the nurse is considering taking should occur only after verifying an abnormal vital sign.

The nurse working on the cardiac unit notes that the client has an S2 murmur, which the nurse understands is caused by: 1. Pulmonic or aortic valve backflow or regurgitation 2. Mitral valve backflow or regurgitation 3. Tricuspid valve backflow or regurgitation 4. Poor coronary arterial circulation

ANS: 1 Closure of aortic and pulmonic valves represents S2, or the second heart sound. Some clients with valvular disease have backflow or regurgitation of blood through the incompetent valve, causing a murmur that you can hear on auscultation. During ventricular diastole the atrioventricular (mitral and tricuspid) valves open and blood flows from the higher-pressure atria into the relaxed ventricles. This represents S1, or the first heart sound. A murmur is caused by blood turbulence, not coronary artery disease

Pregnancy affects a woman's oxygenation needs primarily because of: 1. The increased metabolic demands required to support the fetus 2. The increased tendency to develop anemia as a result of low iron reserves 3. The decreased ability to engage in the physical exercise required to promote circulation 4. The decreased lung capacity resulting from the pressure of the uterus on the diaphragm

ANS: 1 Increased metabolic demands, such as pregnancy or fever and infection, affect a client's oxygen-carrying capacity (of the blood). The remaining options can affect respiratory function but are not the primary cause of increased oxygenation requirements

A 47-year-old female client tells the nurse that her heart feels as though it is racing. The client's pulse is 160 beats per minute. The nurse knows that a vagal response will stimulate the parasympathetic nervous system to slow the heart rate and instructs the client to: 1. Bear down as though she is having a bowel movement 2. Take a hot shower 3. Take a cold bath 4. Hold her breath

ANS: 1 Paroxysmal supraventricular tachycardia is a sudden rapid onset of tachycardia originating above the AV node. It often begins and ends spontaneously. Sometimes excitement, fatigue, caffeine, smoking, or alcohol use precipitates paroxysmal supraventricular tachycardia. When needed, treatment includes vagal stimulation such as carotid sinus massage or Valsalva maneuver to decrease the ventricular response. A hot shower would cause the heart to beat faster in order to cool down the body. A cold bath could cause additional stress and would not be appropriate. Holding the breath will increase the heart rate as it compensates for the lack of oxygen intake and buildup of carbon dioxide.

A device made of rigid plastic that is used for oropharyngeal suctioning is known as a _________________.

ANS: Yankauer, or tonsillar tip, suction device A Yankauer, or tonsillar tip, suction device is used for oropharyngeal suctioning. A Yankauer suction catheter is made of rigid, minimally flexible plastic. 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 can. The Yankauer suction catheter is not used to suction the nares because of its size.

A plastic or rubber tube that is inserted through the nares or mouth past the epiglottis and vocal cords to maintain an airway is known as an _________________.

ANS: endotracheal (ET) tube An ET tube is inserted through the nares (nasal ET tube) or the mouth (oral ET tube) past the epiglottis and vocal cords into the trachea. ET tubes usually are made of plastic or rubber.

A _______________ is inserted directly into the trachea through a small incision made in the patient's neck.

ANS: tracheostomy tube A tracheostomy tube is inserted directly into the trachea through a small incision made in the patient's neck.

The client with a chronic obstructive respiratory disease is receiving oxygen via a nasal cannula. Which of the following interventions does the nurse plan to include in the client's care? 1. Assess nares for skin breakdown every 6 hours. 2. Check patency of the cannula every 2 hours. 3. Inspect the mouth every 6 hours. 4. Check oxygen flow every 24 hours.

ANS: 1 The nurse caring for the client with a nasal cannula should plan to assess the client's nares and superior surface of both ears for skin breakdown every 6 hours. The nurse should check patency of the cannula every 8 hours. The nurse does not need to check the client's mouth in relation to the client's use of a nasal cannula. The nurse should continue providing oral hygiene and may assess the mouth (i.e., tongue) for cyanosis, along with other assessment measures. Oxygen flow should be checked every 8 hours, not every 24 hours.

The nurse is preparing to teach a group of adult women about the signs and symptoms of a myocardial infarction (heart attack). The nurse will include in the teaching plan the results of research that demonstrate women may experience specific symptoms, such as: 1. Visual difficulties 2. Epigastric pain 3. Loss of motor function unilaterally 4. Right scapular discomfort and stiffness

ANS: 2 Epigastric pain is a symptom of a myocardial infarction in women. Visual disturbances, loss of motor function unilaterally, and right scapular discomfort and stiffness are not symptoms of a myocardial infarction in women.

When interviewing a newly admitted client, the nurse learns that the client is a cigarette smoker. It is determined that the client has a 50 pack-year history. This means that the client has smoked: 1. 2 packs of cigarettes a day for 25 years 2. 50 cigarettes a week for the last year 3. 1 pack a week for the last year 4. 50 packs within the last year

ANS: 2 If a client smoked 2 packs a day for 20 years, the client has a 40 pack-year history (packages per day x years smoked).

The nurse is working on a pulmonary unit at the local hospital. The nurse is alert to one of the early signs of hypoxia in the clients, which is: 1. Cyanosis 2. Restlessness 3. A decreased respiratory rate 4. A decreased blood pressure

ANS: 2 Mental status changes are often the first signs of respiratory problems and may include restlessness and irritability. Cyanosis is a late sign of hypoxia. A decreased respiratory rate is not an early sign of hypoxia. The respiratory rate will increase as the body attempts to compensate for the decreased level of oxygen. As the hypoxia worsens, the respiratory rate may decline. During early stages of hypoxia the blood pressure is elevated unless the condition is caused by shock

When performing nasotracheal suctioning, the nurse: a. Inserts the catheter about 20 cm b. Uses clean gloves and equipment to suction c. Applies pressure to insert the catheter through the nares d. Slants the catheter upward through the mouth

ANS: A Nasotracheal suctioning (without applying suction): In adults, insert the catheter about 20 cm; in older children, about 16 to 20 cm (6 to 8 inches); and in young children and infants, 8 to 14 cm (3 to 5½ inches). Apply sterile glove to each hand, or apply nonsterile glove to nondominant hand and sterile glove to dominant hand. Gently but quickly insert the catheter into the nares during inhalation, and following the natural course of the nares, slightly slant the catheter downward or through the mouth. Do not force through the nares.

To perform oral pharyngeal suctioning, what should the nurse do first? a. Apply gloves and mask b. Insert the suction device to the back of the throat c. Remove the patient's nasal cannula d. Connect the tubing to a standard suction catheter

ANS: A See Intervention Skill: 1. Perform hand hygiene and apply gloves. Apply mask or face shield. Insert device into mouth along gum line to pharynx. Move device around mouth until secretions have cleared. Remove patient's oxygen mask, if present. Nasal cannula may remain in place. Keep oxygen mask near patient's face. Connect one end of connecting tubing to suction machine and other to Yankauer suction catheter. May need to use standard suction catheter to reach into trachea if respiratory status is not improved.

What are the goals of correctly inflating the cuff on an artificial airway? (Select all that apply.) a. Promote lung inflation b. Prevent aspiration of gastric contents c. Allow drainage of secretions that accumulate d. Apply maximum pressures to prevent leakage

ANS: A, B, C The goals of correctly inflating the cuff on an artificial airway are to promote lung inflation for mechanical ventilation, to prevent aspiration of gastric contents, and, at the same time, to allow drainage of secretions that accumulate between the epiglottis and the cuff. If the cuff pressures are too high, permanent damage to the tracheal mucosa occurs. Maintain cuff pressures between 20 and 25 mm Hg or less (Roman, 2005).

Airway management involves maintaining the patency of which of the following? (Select all that apply.) a. Nose b. Upper airway c. Trachea d. Lower airway

ANS: A, B, C, D Airway management involves maintaining the patency of the nose, upper airway, trachea, and the lower airway of the respiratory systems

Contraindications to nasotracheal suctioning include which of the following? (Select all that apply.) a. Facial trauma b. Bleeding disorders c. Epiglottis or croup d. Laryngospasm

ANS: A, B, C, D Contraindications to nasotracheal suctioning include facial trauma/surgery, bleeding disorders, nasal bleeding, epiglottitis or croup, laryngospasm, and irritable airway. These conditions are contraindications as the passage of a catheter through the nasal route causes additional trauma, increases nasal bleeding, or causes severe bleeding in the presence of bleeding disorders. In the presence of epiglottitis, croup, laryngospasm, or irritable airway, the entrance of a suction catheter via the nasal route causes intractable coughing, hypoxemia, and severe bronchospasm; this may necessitate emergency intubation or tracheostomy.

The nurse is caring for a patient who has a tracheostomy. To prevent the patient from developing an airway obstruction, the nurse assesses which of the following? (Select all that apply.) a. The patient's fluid status b. Environmental humidity c. The presence of infection d. The patient's anatomy

ANS: A, B, C, D Fluid overload increases the amount of secretions. Dehydration promotes thicker secretions. Environment influences secretion formation and gas exchange, necessitating airway suctioning when the patient cannot clear secretions effectively. Patients with respiratory infections are prone to increased secretions that are thicker and sometimes more difficult to expectorate. Abnormal anatomy impairs normal drainage of secretions (e.g., nasal swelling, deviated septum, and facial fracture may impair nasal drainage).

Risks associated with airway suctioning include which of the following? (Select all that apply.) a. Cardiac dysrhythmias b. Laryngeal spasm c. Bradycardia d. Nasal trauma

ANS: A, B, C, D The suctioning procedure has many risks associated with it. The most serious relate to hypoxemia, which often results in cardiac dysrhythmias; laryngeal spasm; bradycardia, which is associated with stimulation of the vagus nerve; and nasal trauma and bleeding, which can develop from trauma of the suction catheter

Noninvasive techniques that are helpful in maintaining a patent airway include which of the following? (Select all that apply.) a. Hydration b. Emergency tracheostomy c. Deep breathing d. Coughing

ANS: A, C, D Hydration, positioning, nutrition, chest therapy airway clearance techniques, mucous clearance device therapy, deep breathing, coughing, humidity, and aerosol therapy are noninvasive techniques that are helpful in maintaining a patent airway. Emergency tracheostomy is an invasive technique that can be done by a physician only

How do the guidelines for suctioning an infant differ from the guidelines for suctioning an adult? a. Secretions are easier to remove b. Suctioning occurs in 5-second intervals c. Suctioning is done 2 to 3 cm beyond an artificial airway d. The suction catheter measures two thirds of the diameter of a tracheostomy tube

ANS: B Suctioning an infant should require no longer than 5 seconds. An adult requires 10 to 15 seconds. Because of the small diameter of the suction catheter, thick secretions may be more difficult to remove. Distance suctioned should not be greater than 0.5 cm beyond the tip of the artificial airway. Small-diameter suction catheters required in pediatrics should measure one-half the diameter of the child's tracheostomy tube.

The nurse has reviewed information about the cardiovascular system before caring for a client with heart disease. The nurse knows that which of the following statements is true concerning the physiology of the cardiovascular system? 1. Stimulating the parasympathetic system would cause the heart rate to go up. 2. When a person has heart muscle disease, the heart muscles stretches as far as is necessary to maintain function. 3. The QRS interval on the electrocardiogram represents the electrical impulses passing through the ventricles. 4. When stroke volume decreases, there is a resultant decrease in heart rate.

ANS: 3 The QRS complex indicates that the electrical impulse has traveled through the ventricles. Stimulating the parasympathetic system would cause the heart rate to decrease, not increase. In the diseased heart, the stretch of the myocardium is beyond the heart's physiological limits. When stroke volume is decreased, there is an increase in heart rate.

The nurse is reviewing the results of the client's diagnostic testing. Of the following results, the finding that falls within expected or normal limits is: 1. Palpable, elevated hardened area around a tuberculosis skin testing site. 2. Sputum for culture and sensitivity identifies Mycobacterium tuberculosis 3. Presence of acid fast bacilli in sputum 4. Arterial oxygen tension (PaO2) of 95 mm Hg

ANS: 4 A palpable, elevated, hardened area surrounding a tuberculosis skin testing site is indicative of an antigen-antibody reaction and is considered a positive skin test. Sputum for culture and sensitivity noted the presence of an organism and acid fast bacilli. Normal arterial oxygen tension (PaO2) ranges between 95-100 mmHg.

The nurse knows that the client who smokes is how much more likely to develop lung cancer than a nonsmoker? 1. Twice 2. Three times 3. Five times 4. Ten times

ANS: 4 According to the American Cancer Society, the risk for lung cancer is 10 times greater for a person who smokes than for a nonsmoker. Exposure to secondhand smoke increases the risk for lung cancer and cardiovascular disease

A humidity tent is frequently used for infants and young children to liquefy secretions and help reduce a fever. The nurse knows that humidified air puts the client at risk for: 1. Respiratory distress 2. Infection 3. Skin breakdown 4. Hypothermia

ANS: 4 Air in the humidity tent sometimes becomes cool and falls below 20° C (68° F), causing the child to become chilled. Children in humidity tents require frequent changes of clothing and bed linen to remain warm and dry. Humidified air helps in keeping the airway open by providing hydration to liquefy secretions, and the cool environment helps reduce bronchospasms. Humidified air liquefies secretions, allowing the child to cough them up, which reduces the risk for an infection. Humidified air should not lead to skin breakdown as long as the linens and clothing are not allowed to remain wet.

When assisting with PM care for an 82-year-old client recuperating from pneumonia, the nurse observes that the client appears to be uncharacteristically confused, asking "Where am I?" Which of the following interventions is the most therapeutic for this particular client? 1. Listen for lung sounds. 2. Reorient the client to place. 3. Ask some simple questions to confirm the confusion. 4. Assess the client's pulse oximetry reading on room air.

ANS: 4 Because mental status changes are often the first signs of respiratory problems and often include forgetfulness and irritability, assessing the client's blood oxygen is the most therapeutic intervention

The nurse is checking the client's overall oxygenation. In assessment of the presence of central cyanosis, the nurse will inspect the client's: 1. Palms and soles of the feet 2. Nail beds 3. Earlobes 4. Tongue

ANS: 4 Central cyanosis is observed in the tongue, soft palate, and conjunctiva of the eye, where blood flow is high. Central cyanosis indicates hypoxemia. Peripheral cyanosis seen in the palms and soles of the feet, nail beds, or earlobes is often a result of vasoconstriction and stagnant blood flow

A client has been admitted to the emergency department with an aspirin overdose. The nurse anticipates that the client will be experiencing respiratory complications because the nurse knows that aspirin (salicylate) poisoning causes excessive stimulation of the respiratory system as the body attempts to compensate for: 1. Decreased hemoglobin 2. Excess carbon monoxide 3. Decreased oxygen 4. Excess carbon dioxide

ANS: 4 The body is attempting to correct the acid-base balance, so the respiratory system causes the body to breathe faster in order to try to blow off the excessive carbon dioxide. The hemoglobin is not decreased but does not release oxygen to tissues as readily, and tissue hypoxia results. The body does not produce carbon monoxide. Oxygen levels are not decreased, but the body is attempting to compensate for metabolic acidosis by producing a respiratory alkalosis.

The client is experiencing a sinus dysrhythmia with a pulse rate of 82 beats per minute. Upon entering the room, the nurse expects to find the client: 1. Extremely fatigued 2. Complaining of chest pain 3. Experiencing a "fluttering" sensation in the chest 4. Having no clinical signs based on the assessment

ANS: 4 The nurse would expect to find the client experiencing a sinus dysrhythmia at a rate of 82 beats per minute to have no clinical symptoms. The client with atrial fibrillation may complain of fatigue. The client experiencing a sinus dysrhythmia would not be expected to complain of chest pain. The client with atrial fibrillation may complain of a

Chest percussion, vibration, and shaking are indicated for patients with which of the following conditions? a. Osteoporosis b. Sternal pain c. Pneumonia d. Abdominal aneurysm resection

ANS: C Chest physiotherapy (CPT) and coughing maneuvers assist with airway clearance of mucus in patients with retained tracheobronchial secretions. Secretions accumulate in the airways of patients with bronchitis, asthma, cystic fibrosis (CF), pneumonia, and bronchiectasis. The patient's risk for pathological rib fractures often contraindicates rib shaking. The patient's pain threshold often contraindicates rib shaking. Know the patient's medical and surgical history. Certain conditions, such as increased intracranial pressure, spinal cord injury, or abdominal aneurysm resection, bone metastases, and severe osteoporosis, contraindicate the positional changes of postural drainage. Thoracic trauma contraindicates percussion, vibration, and shaking.

A patient develops respiratory distress during suctioning of the endotracheal tube. What should the nurse do? a. Remove and reinsert the catheter b. Continue to remove thick secretions c. Administer oxygen directly through the catheter d. Encourage the patient to cough and deep-breathe

ANS: C If patient develops respiratory distress during the suction procedure, immediately withdraw catheter, and supply additional oxygen and breaths as needed. In an emergency, disconnect suction, and attach oxygen at prescribed flow rate through the catheter.

In the acute care environment, what is the wall suction pressure setting for infants? a. 10 to 30 mm Hg b. 40 to 60 mm Hg c. 80 to 100 mm Hg d. 100 to 150 mm Hg

ANS: C Infants, 80 to 100 mm Hg. Preterm infants require less suction (40 to 60 mm Hg). This pressure is too low. It is less than infant or preterm infants require. Preterm infants require less suction than infants (40 to 60 mm Hg). Adults require suction of 100 to 150 mm Hg. Children require 100 to 120 mm Hg.

A patient's tracheostomy tube is extubated accidentally. What should the nurse do immediately? a. Call the physician b. Mechanically ventilate the patient c. Insert a new tube d. Hold the stoma open with the fingertips

ANS: C Insert a new tube: Replace old tracheostomy tube with new tube. Some experienced nurses or respiratory therapists may be able to quickly reinsert tracheostomy tube. Keep spare tracheostomy tube of same size and kind at bedside in event of emergency replacement. Notify physician after reestablishing airway. Be prepared to manually ventilate patients in whom respiratory distress develops. Reinsert tracheostomy tube. Keep spare tracheostomy tube of same size and kind at bedside in event of emergency replacement

An Acapella device requires that the patient: a. Fill the lungs completely b. Cough while the device is vibrating c. Hold breath for 2 to 3 seconds d. Adjust the device to a medium resistance setting

ANS: C Place the device in the mouth, maintaining a tight seal. Hold breath for 2 to 3 seconds. Take in a breath that is larger than normal, but do not fill the lungs completely. Try not to cough or to exhale for 3 to 4 seconds through the device while it is vibrating. Turn the Acapella frequency adjustment dial counterclockwise to the lowest resistance setting.

The nurse is caring for an infant who has been vomiting and who is having breathing problems. What should the nurse do to suction the infant? a. Place the infant in a supine position b. Suction only when a large amount of mucus is present c. Place the infant in a prone position d. Use bulb syringe and compress the bulb after it is in place

ANS: C Position infants with breathing problems or excessive vomitus in prone position. Maintain healthy infants in supine position. Airways of infants and children are smaller than those of an adult; even small amounts of mucus cause airway obstruction. Compress syringe before insertion to prevent forcing secretions into infant's bronchi.

A patient with which of the following conditions is a candidate for postural drainage? a. Pulmonary edema b. Active hemoptysis c. Bronchiectasis d. Pulmonary embolism

ANS: C Secretions accumulate in patients with bronchitis, asthma, CF, pneumonia, and bronchiectasis. A contraindication for postural drainage is pulmonary edema associated with congestive heart failure, active hemoptysis, and pulmonary embolism.

An Acapella CPT device has been shown to be of greatest benefit to patients experiencing: a. Empyema b. Bronchopleural fistula c. Cystic fibrosis (CF) d. Pleural effusion

ANS: C The Acapella device is one of many airway clearance devices aimed at assisting the patient with CF, chronic obstructive pulmonary disease (COPD), and other lung diseases to easily remove secretions from the airways. CPT is contraindicated in patients with empyema, bronchopleural fistula, and pleural effusion.

When assessing a patient's tracheostomy site, a nurse notes the presence of irritation around the stoma. What should the nurse do to address this problem? a. Decrease the frequency of care b. Apply a dry gauze dressing c. Remove the ties at intervals d. Apply a topical antibacterial solution

ANS: D Apply topical antibacterial solution; allow it to dry and provide bacterial barrier. Increase frequency of tracheostomy care. Apply hydrocolloid or transparent dressing just under stoma to protect skin from breakdown. Consult with skin care specialist. Adjust ties, or apply new ties when ties are loose or tight.

An underinflated ET cuff is suspected with the presence of: a. Tracheomalacia b. Decreased phonation c. Tracheoesophageal fistula d. Aspiration of gastric contents

ANS: D Aspiration and phonation can occur when cuff is underinflated. Tracheomalacia can occur when the cuff is overinflated. Ability for phonation increases when cuff is underinflated. Tracheoesophageal fistula can occur when the cuff is overinflated

After suctioning a patient, a nurse notes the return of bloody secretions. What should the nurse do next? a. Increase the suction pressure b. Provide additional oxygen c. Reduce the frequency of oral hygiene d. Check the suction catheter for nicks

ANS: D Observe catheter tip for nicks, which can cause mucosal trauma. The nurse should reduce the amount of suction pressure used, provide supplemental oxygen only if respiratory distress, and increase the frequency of oral hygiene.

Preparation for tracheostomy care in the acute care environment includes: a. Using clean technique, gloves, and supplies b. Placing the patient in high-Fowler's position c. Removing and cleaning the outer cannula d. Preparing cotton applicators with normal saline and hydrogen peroxide

ANS: D Open two cotton-tipped swab packages, and pour normal saline on one package and leave the other package dry. Open sterile tracheostomy kit. Apply gloves. Keep dominant hand sterile throughout procedure. Assist patient to a position that is comfortable for both nurse and patient (usually supine or semi-Fowler's). While touching only the outer aspect of the tube, remove the inner cannula with nondominant hand. Drop inner cannula into hydrogen peroxide basin.

The physician has ordered that the patient receive percussion and vibration to help clear airway secretions. Where must the nurse place her hands? a. On the patient's clavicles b. On the patient's spine and sternum c. On the patient's abdomen d. On the patient's ribs

ANS: D Perform percussion, vibration, and shaking only over the ribs. The clavicles, breast tissue, sternum, spine, waist, and abdomen are never used for percussion and vibration.

Ventilator-associated pneumonia (VAP) is a major concern for ventilated patients because it: a. Occurs in 5% of ventilated patients b. Causes 75% of nosocomial infections in vented patients c. Develops within 24 hours of intubation d. Increases hospital stay length and mortality

ANS: D VAP causes an increase in hospital stay length and mortality. VAP occurs in 10% to 65% of ventilated patients, causes 90% of nosocomial infections in vented patients, and is defined as developing after 48 hours following intubation.

Upon completion of suctioning, what should the nurse do first? a. Reduce the suction level b. Save the face shield for future suctioning episodes c. Reposition the patient, and complete personal care using sterile gloves d. Pull the gloves off over the rolled catheter, and discard

ANS: D When suctioning is completed, disconnect catheter from connecting tubing. Roll catheter around fingers of dominant hand. Pull glove off inside out so that catheter remains coiled in glove. Pull off other glove over first glove in same way to seal in contaminants. Discard in appropriate receptacle. Turn off suction device. Turn off suction device. There is no further need for the suction. Remove face shield and discard into appropriate receptacle. Perform hand hygiene. Remove towel, place in laundry or appropriate receptacle, and reposition patient. (Nurse may need to wear clean gloves for personal care.)

Too much oxygen reduces the drive to breathe in patients with chronic _____________.

hypercapnia Too much oxygen reduces the drive to breathe in patients with chronic hypercapnia (elevated arterial carbon dioxide tension).

During pretesting for an elective surgery, it is discovered that the older adult client has atrial fibrillation. The nurse knows that this is a common dysrhythmia in older people and can cause: 1. Fatigue, a fluttering in the chest, or shortness of breath if the ventricular response is rapid 2. Acute loss of pulse and respiration 3. Severe hypotension and loss of pulse and consciousness 4. Dizziness, syncope, or chest pain

ANS: 1 There is a loss of the atrial kick (portion of the cardiac output squeezed in the ventricles with a coordinated atrial contraction), pooling of blood in the atria, and development of microemboli. The client often complains of fatigue, a fluttering in the chest, or shortness of breath if the ventricular response is rapid. It is a commonly occurring dysrhythmia in the aging and older adult. Acute loss of pulse and respiration is indicative of ventricular fibrillation. Immediate defibrillation is needed after assessment of ABCs of CPR. Ventricular tachycardia results in decreased cardiac output due to decreased ventricular filling time and often leads to severe hypotension and loss of pulse and consciousness. Sinus bradycardia may present signs and symptoms of reduced cardiac output such as dizziness, syncope, or presence of chest pain

The nurse suspects that a 59-year-old client has experienced angina pectoris. Which of the following assessment questions will most likely produce information that will assist in the diagnosis? 1. "How long did the pain last?" 2. "Can you describe the pain for me?" 3. "Did the pain radiate into your left arm?" 4. "What were you doing when the pain started?"

ANS: 1 Unlike the pain resulting from a myocardial infarction, anginal pain usually lasts from 1 to 15 minutes. The remaining questions could also relate to cardiac pain from other origins

The nurse caring for a morbidly obese client who is recovering from abdominal surgery recognizes that this client is at risk for respiratory complications specifically caused by: (Select all that apply.) 1. Poor muscle tone, resulting in decreased respiratory muscle function 2. Increased risk for infection, resulting in increased oxygen requirements 3. Deceased lung volume resulting from compression of abdominal organs 4. Increased presence of pulmonary secretions in the lower lobes bilaterally 5. Obesity-hypoventilation syndrome resulting from chronic carbon dioxide retention 6. Pain resulting in reluctance to deep breathe and facilitate exchange of oxygen and carbon dioxide

ANS: 1, 2, 3, 4, 5 Morbidly obese clients have a reduction in compliance as a result of encroachment of the abdomen into the chest, increased work of breathing, and decreased lung volumes. In some clients an obesity-hypoventilation syndrome develops in which oxygenation is decreased and carbon dioxide is retained. The obese client is also susceptible to pneumonia after surgery or an upper respiratory tract infection because the lungs do not fully expand and the lower lobes retain pulmonary secretions. Pain is a universal barrier to effective breathing; it is not unique to the obese client.

Which of the following situations would cause the nurse to expect an increase in cardiac output in a client who is experiencing no health issues? (Select all that apply.) 1. After playing a set of doubles' tennis 2. Being 31 weeks' pregnant with twins 3. Upon rising from a 45-minute afternoon nap 4. During a panic attack resulting from an unknown trigger 5. Experiencing a 100° F temperature resulting from a bacterial infection 6. Following a 60-minute session that included aerobic exercise

ANS: 1, 2, 4, 5, 6 Exercise, pregnancy, and fever increase cardiac output, but during sleep it decreases.

A client recently fractured his spinal cord at the C3 level and is at great risk for developing pneumonia primarily because the: 1. Resulting paralysis immobilizes him, and secretions will increase in his lungs 2. Innervation to the phrenic nerve is absent, preventing chest expansion 3. Resulting abnormal chest shape disallows efficient ventilatory movement 4. Trauma decreases the ability of his red blood cells to carry oxygen

ANS: 2 Cervical trauma at C3 to C5 can result in paralysis of the phrenic nerve, preventing chest expansion. Although the increase in lung secretions as a result of immobility is a risk factor, the client's greatest risk is related to the level of his fracture. There is no mention of an abnormal chest shape. This client's greatest risk for developing pneumonia is related to the level of his fracture. If the client were anemic as a result of blood loss from trauma, his oxygen-carrying capacity of blood would be decreased. There is no mention of excessive blood loss, nor would this place him at great risk for developing pneumonia.

All of the following clients are experiencing increased respiratory secretions and require intervention to assist in their removal. Chest percussion is indicated and appropriate for the client experiencing: 1. Thrombocytopenia 2. Cystic fibrosis 3. Osteoporosis 4. Spinal fracture

ANS: 2 Chest percussion is indicated and appropriate for the client with cystic fibrosis to assist in mobilizing the thick pulmonary secretions. Percussion is contraindicated in clients with bleeding disorders, such as the client with thrombocytopenia. Percussion is also contraindicated in the client with osteoporosis and the client with a spinal fracture or with fractured ribs

The client is admitted to the medical center with a diagnosis of right-sided heart failure. In assessment of this client, the nurse expects to find: 1. Dyspnea 2. Confusion 3. Dizziness 4. Peripheral edema

ANS: 4 Peripheral edema is an expected assessment finding in the client diagnosed with right-sided heart failure. Dyspnea is an expected assessment finding in the client diagnosed with left-sided heart failure. Confusion is a symptom of hypoventilation. Dizziness is an expected assessment finding in the client experiencing hypoxia.

The nurse identifies that the client is unable to cough to produce a sputum specimen, and the client's secretions must be suctioned. Which suctioning route is preferred for obtaining this specimen? 1. Nasopharyngeal 2. Nasotracheal 3. Oropharyngeal 4. Orotracheal

ANS: 2 Nasotracheal suctioning is the preferred route for obtaining a sputum specimen when the client is unable to cough to produce a sputum specimen on his or her own. The nasopharyngeal route for suctioning is used when the client is able to cough but is unable to clear secretions by expectorating or swallowing. It is not the preferred route for obtaining a sputum specimen. The oropharyngeal route is used when the client is able to cough but is unable to clear secretions by expectorating or swallowing. It is not the preferred route for obtaining a sputum specimen. The orotracheal route is used when the client is unable to manage secretions by coughing. The nasotracheal route is preferred over the orotracheal route because stimulation of the gag reflex is minimal.

The client has experienced a myocardial infarction resulting in damage to the left ventricle. A possible complication the client may experience that the nurse is alert to is: 1. Jugular neck vein distention 2. Pulmonary congestion 3. Peripheral edema 4. Liver enlargement

ANS: 2 Pulmonary congestion may be experienced in left-sided heart failure. Jugular neck vein distention is characteristic of right-sided heart failure. Peripheral edema is characteristic of right-sided heart failure. Hepatomegaly (liver enlargement) is characteristic of right-sided heart failure

A 64-year-old client is seen in the emergency department for palpitations and mild shortness of breath. The electrocardiogram (ECG) reveals a normal P wave, P-R interval, and QRS complex with a regular rhythm and rate of 108 beats per minute. The nurse should recognize this cardiac dysrhythmia as: 1. Sinus dysrhythmia 2. Sinus tachycardia 3. Supraventricular tachycardia 4. Ventricular tachycardia

ANS: 2 The client is experiencing sinus tachycardia. The rhythm is regular with a normal P wave, normal QRS complex, and a rate of 100 to 180 beats per minute. A sinus dysrhythmia has a rate of 60 to 100 beats per minute and slows during inspiration and increases with expiration. The client is not experiencing a sinus dysrhythmia. With supraventricular tachycardia, the heart rate is 150 to 250 beats per minute, the P wave may be buried in the preceding T wave, and the P-R interval is variable. This client is not experiencing supraventricular tachycardia. With ventricular tachycardia the rhythm is slightly irregular at a rate of 100 to 200 beats per minute, the P wave is absent, the P-R interval is absent, and the QRS complex is wide. This client is not experiencing ventricular tachycardia.

The electrical activity of the client's heart is being continuously monitored while the client is on the coronary care unit. Suddenly the nurse finds that the client is experiencing ventricular fibrillation. The nurse will prepare to: 1. Administer atropine 2. Prepare for cardiopulmonary resuscitation (CPR) 3. Prepare the client for surgical placement of a pacemaker 4. Instruct the client to perform the Valsalva maneuver

ANS: 2 The nurse should prepare for CPR for the client experiencing ventricular fibrillation. Atropine is used for sinus bradycardia with hypotension and decreased cardiac output. In this case, the nurse should prepare to administer CPR, not atropine. A pacemaker may be required for the client with sinus bradycardia. It is not the treatment for ventricular fibrillation. The Valsalva maneuver is used to treat supraventricular tachycardia, not ventricular fibrillation.

The nurse is working on a respiratory care unit in the hospital. Upon entering the room of a client with emphysema, it is noted that the client is experiencing respiratory distress. The nurse should: 1. Instruct the client to breathe rapidly 2. Provide 20% oxygen at 2 L/min via nasal cannula 3. Place the client in the supine position 4. Go to contact the health care provider

ANS: 2 The nurse should provide a low concentration of oxygen to the client. The client should be instructed to use pursed-lip breathing. The most effective position for the client with cardiopulmonary disease is the 45-degree semi-Fowler's position, using gravity to assist in lung expansion and reduce pressure from the abdomen on the diaphragm. The nurse's first priority should be to attend to the client who is in respiratory distress, not to contact the health care provider.

The nurse working on the pulmonary unit is asked to obtain an acid-fast bacillus (AFB) sputum specimen from a client. The nurse knows that this test is used to screen for: 1. Cancer 2. Tuberculosis (TB) 3. Cystic fibrosis 4. Histoplasmosis

ANS: 2 The test is used to screen for the presence of AFB for detection of TB by early morning specimens on 3 consecutive days. Cancer would be tested by a sputum specimen for cytologic examination. Cystic fibrosis and histoplasmosis are not screened for through sputum tests.

The client has supplemental oxygen in place and requires suctioning to remove excess secretions from the airway. To promote maximum oxygenation, an appropriate action by the nurse is to: 1. Suction continuously for 30-second intervals 2. Replace the oxygen and allow rest in between suctioning passes 3. Increase the amount of suction pressure to 200 mm Hg 4. Complete a number of suctioning passes until the catheter comes back clear

ANS: 2 To promote maximum oxygenation, the nurse should replace the oxygen and allow rest in between suctioning passes. Suctioning should be intermittent for up to 10 to 15 seconds. Wall suction is set at 80 to 120 mm Hg; portable suction is set at 7 to 15 mm Hg for adults. Elevated pressure settings, such as 200 mm Hg, increase the risk for trauma to mucosa and can induce greater hypoxia. The number of suctioning passes is determined by client assessment and need. Repeated passes can remove oxygen and may induce laryngospasm. The client is not suctioned until the catheter comes back clear.

The nurse expects to observe which of the following assessment findings in a client diagnosed with left-sided heart failure? (Select all that apply.) 1. Ankle edema 2. Bilateral crackles 3. Mental confusion 4. Distended neck veins 5. Activity-induced dyspnea 6. Being awakened by shortness of breath

ANS: 2, 3, 5, 6 Clinical findings of left-sided heart failure include crackles on auscultation, hypoxia, shortness of breath on exertion and often at rest, cough, and paroxysmal nocturnal dyspnea. The remaining options are more reflective of right-sided failure.

A client who has a history of a major myocardial infarction is taking digoxin. The nurse explains this medication helps increase cardiac output by: 1. Increasing the heart rate 2. Reducing the resistance of pulmonary circulation 3. Increasing the force of the myocardial contraction 4. Increasing cardiac conduction

ANS: 3 Myocardial contractility affects stroke volume and cardiac output. Increased contraction increases the amount of blood ejected by the ventricles. Digoxin increases cardiac output by inhibiting the sodium-potassium ATPase, which makes more calcium available for contractile proteins, which results in a positive inotropic effect. One of the adverse reactions of digoxin is bradycardia. Digoxin does not reduce the resistance of pulmonary circulation or affect the electrical conduction of the heart.

In teaching a client about an upcoming diagnostic test, the nurse identifies that which one of the following uses an injection of contrast material? 1. Holter monitor 2. Echocardiography 3. Cardiac catheterization 4. Exercise stress test

ANS: 3 A cardiac catheterization involves the injection of contrast material in order to visualize the cardiac chambers, valves, the great vessels, and coronary arteries. It also is used to measure the pressures and volumes within the chambers of the heart. A Holter monitor is a portable ECG worn by the client. It does not require contrast media. An echocardiography is a noninvasive measure that graphically depicts overall cardiac performance. An exercise stress test evaluates the cardiac response to the physical stress of the client on a treadmill. Contrast material is not used for this test.

The nurse observes that a client's pulse rate is 58 beats per minute and regular in rhythm. Which of the following statements made by the nurse shows the appropriate understanding of the client's further need for assessment? 1. "I'll wait 15 minutes and reevaluate the client's pulse rate." 2. "Her pulse rate is usually in the mid 60s, so there isn't a problem." 3. "I'll need to assess her for the presence of chest pain and/or dizziness." 4. "You run an electrocardiogram, and I'll notify her health care provider."

ANS: 3 A low but regular heart rate has no clinical significance unless associated with signs and symptoms of reduced cardiac output such as dizziness or syncope or the presence of chest pain.

At a community health fair the nurse informs the residents that the influenza vaccine is recommended for clients: 1. Only older than age 65 2. 40 to 60 years of age 3. In any age-group who have a chronic disease 4. Who have an acute febrile illness

ANS: 3 Annual influenza vaccine is recommended for clients of any age with a chronic disease. Annual influenza vaccine is recommended for clients older than age 65, but this is not the only group. Annual influenza vaccine is recommended for any age-group, including those age 40 to 60, who have a chronic disease of the heart, lung, or kidneys; clients with diabetes; clients with immunosuppression or severe forms of anemia; or those in close or frequent contact with anyone in a high-risk group. Clients with an acute febrile illness should not be vaccinated.

It is suspected that the client's oxygenation status is deteriorating. The nurse is aware that the abnormal assessment finding that represents the most serious indication of the client's decreased oxygenation is: 1. Poor skin turgor 2. Clubbing of the nails 3. Central cyanosis 4. Pursed-lip breathing

ANS: 3 Central cyanosis is the most serious finding because it indicates hypoxemia. Poor skin turgor indicates dehydration. It is not an indication of the client's decreased oxygenation. Clubbing of the nails is found in clients with prolonged oxygen deficiency, endocarditis, and congenital heart defects. It is a change that occurs over time and is not an indication of the client's current deterioration in oxygenation status. Pursed-lip breathing is used to slow expiratory flow. It is not the most serious indication of a client's decreased oxygenation.

The nurse is caring for a client who experienced a flailed chest injury (multiple rib fractures) as a result of a motorcycle accident. The nurse realizes that pain management for this client will directly impact the effectiveness of his respiratory functioning primarily because: 1. Pain increases metabolic needs, thus increasing oxygen consumption 2. Pain increases emotional distress, which can lead to hyperventilation 3. Pain will decrease the client's motivation to deep breathe, contributing to shallow, diminished inspirations 4. Pain will decrease the client's ability to both relax and recuperate, thus extending the period of recovery

ANS: 3 Chest wall trauma and upper abdominal incisions decrease chest wall movement as the client uses shallow respirations to minimize chest wall movement to avoid pain.

The primary reason a client with chronic obstructive pulmonary disease (COPD) often experiences fatigue and activity intolerance is related to: 1. The increased presence of surfactant that results in "sticky" alveoli 2. The presence of chronic infections in the lungs and bronchial tree 3. The extra energy that is needed to exhale the air from the damaged lungs 4. The client's elevated anxiety level related to the air hunger being experienced

ANS: 3 Clients with advanced COPD lose the elastic recoil of the lungs and thorax. As a result, the client's work of breathing increases. Although the remaining options are not incorrect, they are not the primary source of the client's fatigue.

The nurse is preparing an educational handout for older adults with chronic respiratory diseases. To best minimize the risk for infection, the nurse should include which of the following guidelines in the material? 1. Remember to take your respiratory medication on schedule. 2. If you are prescribed breathing treatments, take them as ordered. 3. Avoid large, crowded places, especially during the winter months. 4. Remember to talk with your health care provider about a flu vaccination.

ANS: 3 Clients with cardiopulmonary alterations need to minimize their risk for infection, especially during the winter months. Teach clients to avoid large, crowded places; keep their mouth and nose covered; and be sure to dress warmly, including a scarf, hat, and gloves. This is especially important during the peak of the influenza season. A flu shot may be recommended, but it does not protect against the various other infections commonly encountered. The remaining options are not directly related to infection but are more relevant to general management

A client develops acute renal failure and a resulting metabolic acidosis. The nurse recognizes that the respiratory system compensates through: 1. Hypoventilation and increase of bicarbonate levels in the bloodstream 2. Alternating periods of deep versus shallow breaths to maintain homeostasis of the serum pH 3. Hyperventilation to decrease the serum CO2 level and thereby raise the pH 4. Expansion of the lung tissues to their fullest, which increases the inspiratory reserve volumes to provide more oxygen to the tissues

ANS: 3 The respiratory system tries to correct metabolic acidosis by increasing ventilation to reduce the amount of carbon dioxide and thereby raise the pH. The respiratory system would compensate for metabolic acidosis with increased respirations, not hypoventilation. Bicarbonate is the renal component of acid-base balance, not the respiratory component. The pH measures hydrogen ion concentration. Alternating deep versus shallow breaths is not a compensating mechanism of the respiratory system for metabolic acidosis. The respiratory system does not compensate by expanding the lung tissues to their fullest. In metabolic acidosis, the respiratory system compensates by exhaling a greater amount of carbon dioxide.

On admitting a client, the nurse finds that there is a history of myocardial ischemia. The most disconcerting dysrhythmia for electrocardiography to reveal is: 1. Sinus bradycardia 2. Sinus dysrhythmia 3. Ventricular tachycardia 4. Atrial fibrillation

ANS: 3 Ventricular tachycardia would be the most disconcerting dysrhythmia of the four options. Ventricular tachycardia results in a decreased cardiac output; it may lead to severe hypotension and loss of pulse rate and consciousness. Sinus bradycardia would not be of concern for this client. It is of no clinical significance unless it is associated with signs and symptoms of a decreased cardiac output. Sinus dysrhythmia is of no clinical significance unless dizziness occurs with a decreased rate. Atrial fibrillation is not as detrimental as ventricular tachycardia.

The primary effect of chronic fevers on the body's respiratory functioning is seen in: 1. Increased oxygen requirements that exceed the body's ability to satisfy its needs 2. Increased respiratory rates that tax the body's reserves of stored energy 3. Breakdown of muscle mass, causing ineffective intercostal muscle function 4. The presence of a sense of general malaise that stresses the immune system

ANS: 3 When fever persists, the metabolic rate remains high and the body begins to break down protein stores, resulting in muscle wasting and decreased muscle mass. Respiratory muscles such as the diaphragm and intercostal muscles are also wasted. Although the remaining options are not incorrect, they do not represent the primary effect.

A client has recently had mitral valve replacement surgery. To prevent excess serosanguineous fluid buildup, the nurse anticipates that care will include: 1. Increased oxygen therapy 2. Frequent chest physiotherapy 3. Incentive spirometry on a regularly scheduled basis 4. Chest tube placement in the thoracic cavity

ANS: 4 Chest tubes are inserted to remove air and fluids from the pleural space, to prevent air or fluid from reentering the pleural space, and to reestablish normal intrapleural and intrapulmonic pressures. The client who had mitral valve replacement surgery would be expected to have a chest tube postoperatively to prevent excess fluid buildup in the pleural space. Increased oxygen will not prevent excess fluid buildup. Frequent chest physiotherapy may help facilitate removal of secretions but will not prevent excess fluid buildup. Incentive spirometry is used to promote deep breathing and to prevent or treat atelectasis in the postoperative client. It will not prevent excess fluid buildup.

The nurse is assessing a client with a history of chronic obstructive pulmonary disease. When assessing for the presence of air hunger, the nurse should: 1. Monitor the client's pulse oximetry reading 2. Measure the movement of air by counting respirations 3. Auscultate breath sounds both anteriorly and posteriorly 4. Observe for the elevation of the client's clavicles during inspiration

ANS: 4 During an assessment, observe for elevation of the client's clavicles during inspiration. Elevation of the clavicles during inspiration can indicate ventilatory fatigue, air hunger, or decreased lung expansion. Although the remaining options are assessment methods, they are not as effective for determining air hunger.

The client has chest tubes in place following thoracic surgery. In working with a client who has a chest tube, the nurse should: 1. Clamp the tubes except during client assessments 2. Remove the tubing from the connection to check for adequate suction power 3. Milk or strip the tubes every 15 to 30 minutes to maintain drainage 4. Coil and secure excess tubing next to the client

ANS: 4 If the client is in a chair and the tubing is coiled, the tubing should be lifted every 15 minutes to promote drainage. Care should be taken to ensure the tubing remains secure. Clamping the tubes except during client assessments is an inaccurate statement. Clamping a chest tube is contraindicated when the client is ambulating or being transported. In a water-sealed system, gentle bubbling in the suction-control chamber indicates it is functioning. The suction source may be checked to verify it is on the appropriate setting. In a waterless system, the suction control (float ball) indicates the amount of suction the client's intrapleural space is receiving. The tubing should not be disconnected. The chest tube should be stripped or milked only if indicated (e.g., there is clotted drainage in the tube) (check institutional policy). It is believed that stripping the tube greatly increases intrapleural pressure, which could damage the pleural tissue and cause or worsen an existing pneumothorax. Milking causes less of a pressure change.

A client with a chest tube in place is being transported via stretcher to another room closer to the nurses' station. During the transport the collection unit bangs against the wall and breaks open. The nurse immediately: 1. Clamps the tube 2. Tells the client to hyperventilate 3. Raises the tubing above the client's chest level 4. Places the end of the tube in a container of sterile water

ANS: 4 If the drainage unit is broken, the end of the chest tube can be quickly submerged in a container of sterile water to reestablish the seal. Clamping the chest tube may result in a tension pneumothorax. If the tubing becomes disconnected, the client should be instructed to exhale as much as possible and to cough. The client should not hyperventilate. Raising the tubing above the client's chest level will not help the situation.

The unit manager is orienting a new staff nurse and evaluates which of the following as an appropriate technique for nasotracheal suctioning? 1. Placing the client in a supine position 2. Preparing for a clean or nonsterile technique 3. Suctioning the oropharyngeal area first, then the nasotracheal area 4. Applying intermittent suction for 10 seconds during catheter removal

ANS: 4 Intermittent suction for up to 10 to 15 seconds should be applied during catheter removal to prevent injury to the mucosa. The client is not placed in a supine position. The client is usually placed in a semi-Fowler's position. The client's head is turned to the right to help the nurse suction the left mainstem bronchus, and the client's head is then turned to the left to help the nurse suction the right mainstem bronchus. Nasotracheal suctioning is a sterile procedure. The nasotracheal area should be suctioned first, then the oropharyngeal area. The mouth and pharynx contain more bacteria than the trachea.

A client asks the nurse, "I was told that my heart is beating in normal sinus rhythm (NSR). What does that mean?" The nurse replies most therapeutically when responding with which of the following? 1. "Are you worried about how your heart is working?" 2. "It means your heart is working just the way it is supposed to work." 3. "A damaged heart doesn't beat in normal sinus rhythm like yours does." 4. "Each beat starts in the SA node and then causes the chambers to contract."

ANS: 4 NSR implies that the impulse originates at the SA node and follows the normal sequence through the conduction system.

A client diagnosed with chronic bronchitis is awakened from sleep experiencing shortness of breath. The nurse suspects that he is experiencing orthopnea and suggests positioning him to minimize the dyspnea so he can sleep more peacefully. The nurse best describes this position to the client as: 1. "I'll use pillows to take the pressure off your lungs so that they can expand more effectively." 2. "By leaning forward and resting on these pillows, you will be least likely to be short of breath." 3. "This is an upright position that you will be comfortable in and able to breathe more effectively." 4. "We'll place two pillows behind your back so you are sitting more upright; that will let you rest better."

ANS: 4 Orthopnea is an abnormal condition in which the client uses multiple pillows when lying down or must sit with the arms elevated and leaning forward to breathe. The number of pillows used, such as two or three pillows, usually helps to quantify the orthopnea (e.g., two- or three-pillow orthopnea).

The nurse is completing a physical examination for a client who is anemic. In assessing the client's eyes, a sign assessed by the nurse that is consistent with the diagnosis is: 1. Xanthelasma 2. Petechiae 3. Corneal arcus 4. Pale conjunctiva

ANS: 4 Pale conjunctiva is an assessment finding consistent with the diagnosis of anemia. Xanthelasma is caused by hyperlipidemia. Petechiae appear on the skin in clients with platelet deficiency (thrombocytopenia). Petechiae on the conjunctivae is consistent with a fat embolus or bacterial endocarditis. Corneal arcus is caused by hyperlipidemia in young to middle-age adults. It is a normal finding in older adults with arcus senilis.

A 45-year-old male client shares with the nurse that he has noticed that when he is anxious he feels short of breath. The nurse shares with the client that dyspnea can be caused by many conditions and that the client can make an objective assessment of the severity of the dyspnea by using which of the following? 1. Peak expiratory flow rate meter (PEFR) 2. Chest x-ray examination 3. Pulmonary function test 4. Visual analog scale from 1 to 10

ANS: 4 The use of a visual analog scale (VAS) helps clients to make an objective assessment of their dyspnea. The visual analog scale is a 100-mm vertical line; 0 is equated with no dyspnea, and 100 is equated with the worst breathlessness the client has experienced. The use of the VAS to evaluate the level of a client's dyspnea is useful in evaluating nursing interventions designed to reduce dyspnea. The PEFR reflects changes in large airway sizes and is an excellent predictor of overall airway resistance in the client with asthma. Daily measurement is for early detection of asthma exacerbations. Chest x-ray examination is used to observe the lung fields for fluid, masses, fractures, pneumothorax, and other abnormal processes. The pulmonary function test determines the ability of the lungs to efficiently exchange oxygen and carbon dioxide. It is used to differentiate pulmonary obstructive from restrictive disease.

The nurse is preparing to discuss myocardial infarctions (MIs) with a women's group. Which of the following assessment findings should be included when discussing the typically observed signs and symptoms in females experiencing an MI? 1. Originates both at rest and upon exertion 2. Pain lasting longer than 30 minutes 3. Pain radiating up into left jaw 4. Significant gastric indigestion

ANS: 4 There is a significant difference between men and women in relation to coronary artery disease. Women's symptoms differ from those seen in men. The most common initial symptom in women is angina, but atypical symptoms of fatigue, "indigestion," vasospasm, shortness of breath, or back or jaw pain are also present. The remaining options are reflective of symptoms experienced by both men and women.

A client with a suspected narcotic (heroin) overdose is brought to the emergency department by the police. The nurse anticipates that assessment findings will reveal: 1. Agitation 2. Hyperpnea 3. Restlessness 4. Decreased level of consciousness

ANS: 4 With a narcotic overdose, the respiratory center is depressed, reducing the rate and depth of respiration and the amount of inhaled oxygen. The client may display signs of hypoventilation, such as a decreased level of consciousness. A narcotic (heroin) overdose would cause sedation and respiratory depression, not agitation. The client would experience bradypnea, not hyperpnea. A narcotic (heroin) overdose would cause sedation and respiratory depression, not restlessness

Which of the following are factors that affect the blood's capacity to carry sufficient oxygen to the various body organs? (Select all that apply.) 1. The size of the individual 2. The age of the individual 3. The gender of the individual 4. The amount of oxygen present in the blood 5. The amount of hemoglobin present in the blood 6. The amount of oxyhemoglobin present in the blood

ANS: 4, 5, 6 Three things influence the capacity of the blood to carry oxygen: the amount of dissolved oxygen in the plasma, the amount of hemoglobin, and the tendency of hemoglobin to bind with oxygen. The remaining options are not directly involved.

When teaching the family how to provide CPT and postural drainage (PD) for their loved one at home, what instructions does the nurse provide? a. The best times for treatments are usually in the morning before breakfast and 1 hour before bedtime. b. The patient will tell you when he or she needs treatment. c. The family needs to hire a physiotherapist to come in and do the treatments. d. Increase the physiotherapy sessions during acute exacerbations of asthma to keep the airways clear.

ANS: A The best times for treatments are (1) in the morning before breakfast, when the patient can clear secretions that accumulate overnight, and (2) about 1 hour before bedtime so that lungs are clear before sleeping and the patient has time after treatment to cough up any mobilized secretions. Frequency depends on need and patient tolerance and varies from once daily to every 2 to 4 hours in an acute situation. Instruct patient's family or primary caregiver to recognize when the patient's respiratory status requires breathing exercises or postural drainage. The patient may be unable to tell. The patient and family may receive instruction on how to provide home CPT and postural drainage. CPT is not recommended during acute exacerbations of asthma.

What is the purpose of the cuff that is molded onto the endotracheal (ET) tube? (Select all that apply.) a. Prevents aspiration b. Obstructs the escape of air from the ventilator c. Allows gastric contents access to airways d. Obstructs the escape of air from the lower airway

ANS: A, B Adult sizes of ET tubes have a cuff molded onto the tube to (1) prevent the aspiration of oral secretions or gastric contents into the lung and/or (2) obstruct the escape of air from mechanical ventilator breaths through the upper airway

Interventions that are advantageous in preventing ventilator-associated pneumonia (VAP) include which of the following? (Select all that apply.) a. Changing the patient's position every 30 minutes b. Providing oral care with a toothbrush every 8 hours c. Maintaining the endotracheal cuff pressures at 40 mm Hg d. Keeping the head flat especially after feedings

ANS: A, B Best practice guidelines indicate that the following interventions are advantageous in preventing VAP: elevating the head of the bed at 30 to 40 degrees to prevent aspiration, changing patient position every 30 minutes to decrease risk for atelectasis and pulmonary infection, providing oral care with a toothbrush every 8 hours to remove dental plaque organisms (Toothettes are not adequate to clean dental plaque, but they may be used between brushing for comfort), maintaining the endotracheal cuff pressures at 20 cm H2O to decrease movement of secretions to the lower airways, and carefully monitoring patient for aspiration when enteral feedings are infusing.

A nurse notes an excessive air leak of the endotracheal (ET) cuff when auscultating. What should the nurse do to address this problem? a. Deflate the cuff b. Reposition the patient c. Insert a new ET tube d. Apply clamps to the tubing

ANS: B Reposition patient or tubing. Reinflate cuff if needed. Prepare for insertion of new tube by physician or trained personnel if cuff ruptures. Applying clamps to tubing may damage tubing and does not change air in cuff.

Suctioning is discontinued if the patient experiences: a. Coughing b. A decrease in pulse from 84 beats per minute to 60 beats per minute c. An increase in pulse from 84 beats per minute to 94 beats per minute d. A reduction in oxygen saturation from 97% to 94%

ANS: B If the patient's pulse drops more than 20 beats per minute, cease suctioning. The patient should cough. This is expected. Pull the catheter back 1 cm (½ inch). Continue with normal suction procedure. If the patient's pulse increases more than 40 beats per minute or pulse oximetry falls below 90% or 5% from baseline, cease suctioning.

A critical point in performing endotracheal tube (ET) care is: a. Leaving sufficient slack in the tape b. Holding the tube firmly in place at all times c. Suctioning the patient after care is provided d. Removing the oral airway if patient is biting on the ET tube

ANS: B Instruct helper to apply pair of gloves and hold ET tube firmly at patient's lips or nares. Do not allow helper to hold the tube away from the lips or nares. Doing so allows too much "play" in the tube and increases the risk for tube movement and incidental extubation. Never let go of the ET tube, even for a moment. The tube must be secure so that the position of the tube remains at the correct depth. The tube can be secured without being tight and causing pressure. Administer endotracheal, nasopharyngeal, and oropharyngeal suction before cleaning around tube, oral cavity, or dressing site. Do not remove oral airway if patient is actively biting ET tube. Wait until tape is partially or completely secured to ET tube.

In the acute care environment, what is the wall suction pressure setting for adults? a. 20 to 40 mm Hg b. 80 to 100 mm Hg c. 100 to 150 mm Hg d. 100 to 120 mm Hg

ANS: C Adults require suction of 100 to 150 mm Hg. Suction pressure of 20 to 40 mm Hg is too low for adults; it is even less than infants or preterm infants require. 80 to 100 mm Hg is also too low for adults, although it would be appropriate for infants. 100 to 120 mm Hg would be appropriate for children

The nurse is providing nasotracheal suction for a patient. Which of the following is proper technique? a. Insert the catheter during exhalation b. Insert the catheter while the patient is swallowing c. Apply suction only when pulling the catheter out d. Remove the catheter immediately and quickly if patient coughs

ANS: C Never apply suction during insertion. Be sure to insert the catheter during patient inhalation, especially if inserting the catheter into the trachea, because the epiglottis is open. Do not insert during swallowing, or the catheter most likely will enter the esophagus. If the patient gags or becomes nauseated, the catheter is most likely in the esophagus and you need to remove it. The patient should cough. This is expected. Pull the catheter back 1 cm (½ inch). Continue with the normal suction procedure.

An appropriate step for the nurse to take when providing tracheostomy care when the tracheostomy tube has an inner cannula is: a. Suctioning the patient after the procedure b. Removing the old ties before applying the new ones c. Rinsing the inner cannula with saline d. Cleaning the inside of the outer cannula toward the stoma site

ANS: C While touching only the outer aspect of the tube, remove the inner cannula with nondominant hand. Drop inner cannula into normal saline basin. Remove inner cannula for cleaning. Normal saline loosens secretions from inner cannula. Suction tracheostomy before performing the procedure. This removes secretions to avoid occluding outer cannula while inner cannula is removed. If working without an assistant, do not cut old ties until new ties are in place and securely tied. Using dry 4 4 inch gauze, pat lightly at skin and exposed outer cannula surfaces.

When suctioning a ventilated patient with a closed (in-line) system for suctioning of an ET or tracheostomy tube, the nurse knows that: a. No complications are associated with its use b. This system has a greater risk for infection than do open systems c. The artificial airway does not have to be disconnected d. Suctioning with an in-line system interrupts oxygenation

ANS: C With a closed system method, the patient's artificial airway is not disconnected from the mechanical ventilator. The nurse should reassess cardiopulmonary status, including pulse oximetry, to determine the need for subsequent suctioning or complications. Some institutions use a closed suction catheter system or in-line suction catheter device to assist in minimizing infection, especially in critically ill or immunosuppressed patients. Use of a closed system catheter (in-line) allows quicker lower airway suctioning and does not interrupt ventilation and oxygenation in critically ill patients.

The nurse notes that her ventilated patient needs suctioning via his tracheostomy tube. From experience, she knows that the patient has thick, tenacious mucus that is often difficult to remove. One option to help remove those secretions is the practice of normal saline instillation (NSI) into the tracheostomy tube. What risks does the nurse realize accompany the use of NSI? a. Increases the amounts of secretions b. Increases oxygen saturation c. Decreases heart rate d. May increase the potential of ventilated-associated pneumonia

ANS: D Clinical studies comparing the results of suctioning using NSI with standard suctioning note that the use of isotonic normal saline (INS) with suctioning has the potential to increase ventilated-associated pneumonia because INS can dislodge bacteria from the upper airway to the lower portions of the airway. Review of literature indicates that suctioning with or without INS produces similar amounts of secretions. Review of literature indicates that suctioning with or without INS as opposed to dry suctioning significantly decreases oxygen saturation and increases heart rate for 4 to 5 minutes after suctioning with INS.

What should the nurse do to improve the effectiveness of tracheal suctioning? a. Suction for 20-second intervals b. Pass the catheter through to the carina c. Suction during insertion of the catheter d. Hyperinflate and/or hyperoxygenate before suctioning

ANS: D Hyperoxygenation provides some protection from suction-induced decline in oxygenation. Hyperoxygenation is most effective in the presence of hyperinflation such as encouraging the patient to deep breathe or increasing ventilator tidal volume settings. Suctioning longer than 10 seconds can cause cardiopulmonary compromise, usually from hypoxemia or vagal overload. If resistance is felt after insertion of the catheter for a maximum recommended distance, the catheter has probably hit the carina. Pull the catheter back 1 to 2 cm before applying suction. Application of suction pressure while the catheter is introduced into the trachea increases the risk for damage to the mucosa and increases the risk for hypoxia because entrained oxygen present in the airways is removed.

The nurse is caring for a patient who is sedated and is on a ventilator. When assessing the patient, the nurse notes that there is a sound that may indicate that air is escaping around the tube. What should the nurse do? a. Prepare for reintubation b. Repeat taping or securing procedure c. Suction the patient d. Verify correct position of the tube and assess cuff pressure

ANS: D If air is escaping around the tube, verify correct position of tube. If tube position is correct, assess proper cuff inflation. If tube position is incorrect, reposition according to protocol or notify physician. In case of unexpected extubation, remain with patient, call for assistance, assist respirations with bag-valve mask as needed, assess patient for airway patency, spontaneous breathing, and vital signs, and prepare for reintubation. Air escaping from around the tube is not usually an indicator of extubation. Repeat taping or securing procedure when there is movement of the endotracheal tube. Suction the patient if unequal breath sounds are noted. Evaluate ET tube for proper depth before and after ET tube care

The nurse is instructing the patient on how to use his Acapella device. What should the nurse tell the patient to do? a. Take a full breath in and fill his lungs b. Hold his breath for 5 to 10 seconds c. Cough forcefully to clear the lungs d. Exhale slowly for 3 to 4 seconds

ANS: D Instruct the patient to try not to cough and to exhale slowly for 3 to 4 seconds through the device while it vibrates. Take in a breath that is larger than normal, but do not fill the lungs completely. Instruct patient to inhale to about 75% of inspiratory capacity. Hold breath for 2 to 3 seconds. Try not to cough.