PrepU Med-Surg Chapter 21

When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for how long? 10 to 15 seconds 30 to 35 seconds 0 to 5 seconds 20 to 25 seconds

10 to 15 seconds In general, the nurse should apply suction no longer than 10 to 15 seconds because hypoxia and dysrhythmias may develop, leading to cardiac arrest. Applying suction for 30 to 35 seconds is hazardous and may result in the patient's developing hypoxia, which can lead to dysrhythmias and, ultimately, cardiac arrest. Applying suction for 20 to 25 seconds is hazardous and may result in the patient's developing hypoxia, which can lead to dysrhythmias and, ultimately, cardiac arrest. Applying suction for 0 to 5 seconds would provide too little time for effective suctioning of secretions.

After suctioning a tracheostomy tube, the nurse assesses the client to determine the effectiveness of the suctioning. Which findings indicate that the airway is now patent? A respiratory rate of 28 breaths/minute with accessory muscle use Increased pulse rate, rapid respirations, and cyanosis of the skin and nail beds Effective breathing at a rate of 16 breaths/minute through the established airway Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds

Effective breathing at a rate of 16 breaths/minute through the established airway Proper suctioning should produce a patent airway, as demonstrated by effective breathing through the airway at a normal respiratory rate of 12 to 20 breaths/minute. The other options suggest ineffective suctioning. A respiratory rate of 28 breaths/minute and accessory muscle use may indicate mild respiratory distress. Increased pulse rate, rapid respirations, and cyanosis are signs of hypoxia. Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds indicate respiratory secretion accumulation.

The nurse is performing client education for a client who is being discharged on mini-nebulizer treatments. What information should the nurse prioritize in the client's discharge teaching? How to independently wean herself from treatment How to count her respirations accurately How to perform diaphragmatic breathing How to collect serial sputum samples

How to perform diaphragmatic breathing Diaphragmatic breathing is a helpful technique to prepare for proper use of the small-volume nebulizer.

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside? Oxygen analyzer Tracheostomy cleaning kit Manual resuscitation bag Water-seal chest drainage set-up

Manual resuscitation bag

The nurse is teaching the client in respiratory distress ways to prolong exhalation to improve respiratory status. The nurse tells the client to Hold the breath for 5 seconds and then exhale. Initially inhale through the mouth. Purse the lips when exhaling air from the lungs. Sit in an upright position only.

Purse the lips when exhaling air from the lungs.

A client with end-stage chronic obstructive pulmonary disease (COPD) requires bi-level positive airway pressure (BiPAP). While caring for the client, the nurse determines that bilateral wrist restraints are required to prevent compromised care. Which client care outcome is associated with restraint use in the client who requires BiPAP? The client will remain infection-free. The client will remain pain-free. The client will maintain adequate oxygenation. The client will maintain adequate urine output.

The client will maintain adequate oxygenation.

A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct? "Before you do the exercise, I'll give you pain medication if you need it." "Breathe in and out quickly." "Don't use the incentive spirometer more than 5 times every hour." "You need to start using the incentive spirometer 2 days after surgery."

"Before you do the exercise, I'll give you pain medication if you need it."

The nurse is preparing to perform chest physiotherapy (CPT) on a client. Which statement by the client tells the nurse that the procedure is contraindicated. "I have been coughing all morning and am barely bringing anything up." "I just changed into my running suit; we can do my CPT now." "I just finished eating my lunch, I'm ready for my CPT now." "I received my pain medication 10 minutes ago, let's do my CPT now."

"I just finished eating my lunch, I'm ready for my CPT now."

A client's plan of care specifies postural drainage. What action should the nurse perform when providing this noninvasive therapy? Administer the treatment with the client in a high Fowler's or semi-Fowler's position. Assist the client into a position that will allow gravity to move secretions. Perform the procedure immediately following the client's meals. Apply percussion firmly to bare skin to facilitate drainage.

Assist the client into a position that will allow gravity to move secretions.

A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs? Arterial blood gas (ABG) levels Inspection Chest X-ray Auscultation

Auscultation

The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result? Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing Promote the client's ability to take in oxygen Promote the strengthening of the client's diaphragm Promote more efficient and controlled ventilation and to decrease the work of breathing

Improve oxygen transport, induce a slow, deep breathing pattern, and assist the patient to control breathing

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? Partial pressure of arterial carbon dioxide (PaCO2) Partial pressure of arterial oxygen (PaO2) pH Bicarbonate (HCO3-)

Partial pressure of arterial oxygen (PaO2)

The client is postoperative for a total laryngectomy and has recovered from anesthesia. The client's respirations are 32 breaths/minute, blood pressure is 102/58, and pulse rate is 104 beats/minute. Pulse oximetry is 90%. The client is receiving humidified oxygen. To aid in the client's respiratory status, the nurse places the client in which of the following positions. Supine Semi-fowler's Side lying Prone

Semi- Fowler's The client is in respiratory distress. The best position for the client who has a tracheostomy and recovered from anesthesia is semi-Fowler's.

A client with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the health care provider to prescribe? Venturi mask Non-rebreather air mask Tracheostomy collar Face tent

Venturi mask The Venturi mask provides the most accurate method of oxygen delivery.

The home care nurse is planning to begin breathing retraining exercises with a client newly admitted to the home health service. The home care nurse knows that breathing retraining is especially indicated if the client has what diagnosis? Lung cancer Pneumonia Asthma COPD

COPD

A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings? 58 mm Hg 45 mm Hg 120 mm Hg 84 mm Hg

84 mm Hg

A nurse is teaching a client how to perform flow type incentive spirometry prior to his scheduled thoracic surgery. What instruction should the nurse provide to the client? "Take a deep breath and then blow short, forceful breaths into the spirometer." "Breathe in deeply through the spirometer, hold your breath briefly, and then exhale." "Hold the spirometer at your lips and breathe in and out like you normally would." "When you're ready, blow hard into the spirometer for as long as you can."

"Breathe in deeply through the spirometer, hold your breath briefly, and then exhale." The patient should be taught to lace the mouthpiece of the spirometer firmly in the mouth, breathe air in through the mouth, and hold the breath

A nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority? Posting a "No smoking" sign over the client's bed Applying an oil-based lubricant to the client's mouth and nose Changing the mask and tubing daily Assessing the client's respiratory status, orientation, and skin color

Assessing the client's respiratory status, orientation, and skin color

A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education? Inform the patient that using the spirometer is not necessary if the patient is experiencing pain. Have the patient lie in a supine position during the use of the spirometer. Encourage the patient to try to stop coughing during and after using the spirometer. Encourage the patient to take approximately 10 breaths per hour, while awake.

Encourage the patient to take approximately 10 breaths per hour, while awake.

The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique? Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes. Use aerosol sprays to deodorize the client's environment after postural drainage. Perform this measure with the client once a day. Administer bronchodilators and mucolytic agents following the sequence.

Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes. Postural drainage is usually performed two to four times daily, before meals (to prevent nausea, vomiting, and aspiration) and at bedtime. Prescribed bronchodilators, water, or saline may be nebulized and inhaled before postural drainage to dilate the bronchioles, reduce bronchospasm, decrease the thickness of mucus and sputum, and combat edema of the bronchial walls. The nurse instructs the client to remain in each position for 10 to 15 minutes and to breathe in slowly through the nose and out slowly through pursed lips to help keep the airways open so that secretions can drain while in each position. If the sputum is foul-smelling, it is important to perform postural drainage in a room away from other patients or family members. (Deodorizers may be used to counteract the odor. Because aerosol sprays can cause bronchospasm and irritation, they should be used sparingly and with caution.)

A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm? A change in the oxygen concentration without resetting the oxygen level alarm A disconnected ventilator circuit Kinking of the ventilator tubing An ET cuff leak

Kinking of the ventilator tubing Conditions that trigger the high-pressure alarm include kinking of the ventilator tubing, bronchospasm, pulmonary embolus, mucus plugging, water in the tube, and coughing or biting on the ET tube. The alarm may also be triggered when the client's breathing is out of rhythm with the ventilator. A disconnected ventilator tube or an ET cuff leak would trigger the low-pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would trigger the oxygen alarm, not the high-pressure alarm.

The nurse is caring for a client who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. What method of oxygen delivery is most appropriate for the client's needs? Non-rebreathing mask Simple mask Partial-rebreathing mask Nasal cannula

Nasal cannula A nasal cannula is used when the patient requires a low to medium concentration of oxygen for which precise accuracy is not essential. The Venturi mask is used primarily for patients with COPD because it can accurately provide an appropriate level of supplemental oxygen, thus avoiding the risk of suppressing the hypoxic drive. The patient's respiratory status does not require a partial- or non-rebreathing mask.

A client who must begin oxygen therapy asks the nurse why this treatment is necessary? What would the nurse identify as the goals of oxygen therapy? Select all that apply. To reduce stress on the myocardium To clear respiratory secretions To provide visual feedback to encourage the client to inhale slowly and deeply To decrease the work of breathing To provide adequate transport of oxygen in the blood

To reduce stress on the myocardium To provide adequate transport of oxygen in the blood To decrease the work of breathing

Which is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means? T-piece Partial-rebreathing mask Venturi mask Nasal cannula

Venturi mask