Unit #6 ALL -Ventilation and oxygenation

The nurse is assessing a client with chronic obstructive pulmonary disease. With a finger sensor, the nurse measures the client's oxygen saturation with a pulse oximeter machine and obtains a reading of 78% while the client is on oxygen via nasal cannula at 2 L/min. The client is showing no signs of restlessness or dyspnea. What is the first nursing action? 1. Increase the client's oxygen to 4 L/min. 2. Check the finger sensor's position and repeat the test. 3. Notify the client's primary health care provider (PHCP) about the low reading. 4. Check the client's chart to find out what the previous readings have been.

2. Check the finger sensor's position and repeat the test. **Note that the low reading does not match the client's signs and symptoms. The first action by the nurse is to ensure that the test was done properly and the reading is accurate. **The nurse would not increase the oxygen without a PHCP's prescription. The results of the test would be verified before any other actions are taken, and this can be done quickly.

A client is on continuous mechanical ventilation (CMV), and the low-pressure alarm sounds. The nurse would take which action? 1. Make sure that the client is not lying on the ventilator tubing. 2. Determine whether there are any disconnections in the ventilator tubing. 3. Check to see if the client is biting on the endotracheal tube (ETT). 4. Auscultate the lungs to determine whether the client needs to be suctioned.

2. Determine whether there are any disconnections in the ventilator tubing. **The low-pressure alarm can be caused by disconnected tubing, ETT cuff leak, or apnea. **High-pressure alarms can be triggered by increased airway resistance, which can occur with excess secretions in the airway, biting the tube, coughing, bronchospasm, a kinked ventilatory circuit, or excess condensation of water in the ventilator tubing.

The nurse is preparing to obtain a sputum specimen from a client. Which nursing action will facilitate obtaining the specimen? 1. Limiting fluids 2. Having the client take 3 to 4 deep breaths 3. Asking the client to spit into the collection container 4. Asking the client to obtain the specimen after eating

2. Having the client take 3 to 4 deep breaths **To obtain a sputum specimen, the client would rinse the mouth to reduce contamination, breathe deeply, and then cough into a sputum specimen container. The client needs to be encouraged to cough and not spit so as to obtain sputum. Sputum can be thinned by fluids or by a respiratory treatment such as inhalation of nebulized saline or water. The optimal time to obtain a specimen is on arising in the morning.

The nurse is preparing to wean a client from a ventilator by the use of a T-piece. Which would be a component of the plan of care with this type of weaning process? Select all that apply. 1. Pressure support is added to the oxygen system. 2. The T-piece is connected to the client's artificial airway. 3. The client is removed from the mechanical ventilator for a short period of time. 4. The respiratory rate on the ventilator is gradually decreased until the client can do all of the work of breathing on their own. 5. Supplemental oxygen is provided through the T-piece at a fraction of inspired oxygen (FiO2) that is 10% higher than a ventilator setting.

2. The T-piece is connected to the client's artificial airway. 3. The client is removed from the mechanical ventilator for a short period of time. 5. Supplemental oxygen is provided through the T-piece at a fraction of inspired oxygen (FiO2) that is 10% higher than a ventilator setting. **The T-piece (or Briggs device) requires that the client be removed from the mechanical ventilation for short periods of time, usually beginning with a 5-minute period. The ventilator is disconnected, and the T-piece is connected to the client's artificial airway. Supplemental oxygen is provided through the device, often at a FiO2 that is 10% higher than the ventilator setting. **Option 4 describes intermittent mandatory ventilation/synchronized intermittent mandatory ventilation. Pressure support may be prescribed to open alveoli in some clients while on mechanical ventilation.

A client who is mouth breathing is receiving oxygen by face mask. The assistive personnel (AP) asks the registered nurse (RN) why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The RN responds that this feature facilitates which purpose? 1. Prevents the client from getting a nosebleed 2. Gives the client added fluid via the respiratory tree 3. Humidifies the oxygen that is bypassing the client's nose 4. Prevents fluid loss from the lungs during mouth breathing

3. Humidifies the oxygen that is bypassing the client's nose **The purpose of the water bottle is to humidify the oxygen that is bypassing the nose during mouth breathing. **A client who is breathing through the mouth is not at risk for nosebleeds. The humidified oxygen may help keep mucous membranes moist, but it will not substantially alter fluid balance.

A young adult client has never had a chest x-ray before and expresses to the nurse a fear of experiencing some form of harm from the test. Which statement by the nurse provides valid reassurance to the client? 1. "You'll wear a lead shield to partially protect your organs from harm." 2. "The amount of x-ray exposure is not sufficient to cause DNA damage." 3. "The test isn't harmful at all. The most frustrating part is the long wait in radiology." 4. "The x-ray exam itself is painless, and a lead shield protects you from the minimal radiation."

4. "The x-ray exam itself is painless, and a lead shield protects you from the minimal radiation." **Clients would be taught that the amount of exposure to radiation is minimal and that the test itself is painless. The wording in each of the other options is only partly true and therefore cannot provide valid reassurance to the client.

A client suspected of having lung cancer is to undergo pleural biopsy at the bedside. When planning for any potential complications of the procedure, the nurse would have which item(s) available at the bedside? 1. Intubation tray 2. Morphine sulfate injection 3. Portable chest x-ray machine 4. Chest tube and drainage system

4. Chest tube and drainage system **Complications following pleural biopsy include hemothorax, pneumothorax, and temporary pain from intercostal nerve injury. The nurse would have a chest tube and drainage system available at the bedside for use if hemothorax or pneumothorax develops. **An intubation tray is not indicated. The client may be premedicated before the procedure, or a local anesthetic is used. A portable chest x-ray machine would be needed to verify placement of a chest tube if one was inserted, but it is unnecessary to have at the bedside before the procedure.

A client has just returned to a nursing unit following bronchoscopy. Which nursing intervention would the nurse implement? 1. Administering atropine intravenously 2. Administering small doses of a sedative 3. Encouraging additional fluids for the next 24 hours 4. Ensuring the return of the gag reflex before offering food or fluids

4. Ensuring the return of the gag reflex before offering food or fluids **After bronchoscopy, the nurse keeps the client on NPO (nothing by mouth) status until the gag reflex returns because the preoperative sedation and local anesthesia impair swallowing and the protective laryngeal reflexes for a number of hours. **Additional fluids are unnecessary because no contrast dye is used that would need flushing from the system. Atropine and a sedative would be administered before the procedure, not after.

A client with exacerbation of heart failure is being prepared for a thoracentesis. The nurse would assist the client to which position for the procedure? 1. Lying in bed on the affected side 2. Lying in bed on the unaffected side 3. Left lateral recumbent position with the head of the bed flat 4. Prone with the head turned to the side and supported by a pillow

2. Lying in bed on the unaffected side **To facilitate removal of fluid from the chest, the client is positioned sitting at the edge of the bed leaning over the bedside table, with the feet supported on a stool; or lying in bed on the unaffected side with the head of the bed elevated 30 to 45 degrees.

The client with lung cancer and a right-sided pleural effusion seen on chest x-ray is being prepared for a thoracentesis. The nurse would assist the client to which position for the procedure? 1. Supine position, with the head of the bed flat 2. Prone, with the head turned to the side supported by a pillow 3. Left side-lying position, with the head of the bed elevated 45 degrees 4. Right side-lying position, with the head of the bed elevated 45 degrees

3. Left side-lying position, with the head of the bed elevated 45 degrees **To facilitate removal of fluid from the pleural space, two positions may be used. The client may be positioned sitting on the edge of the bed, leaning over the bedside table, with the feet supported on a stool. The other position is lying in bed on the unaffected side, with the head of the bed elevated 45 degrees (Fowler's position).

A client with a tracheostomy tube who is on a ventilator is at risk for reduced gas exchange. The nurse would assess for which finding as the best indicator of adequate ongoing respiratory status? 1. Oxygen saturation of 89% 2. Respiratory rate of 16 breaths/minute 3. Moderate amounts of tracheobronchial secretions 4. Small to moderate amounts of frank blood suctioned from the tube

2. Respiratory rate of 16 breaths/minute **Impaired gas exchange could occur after tracheostomy because of excessive secretions, bleeding into the trachea, restricted lung expansion because of immobility, or concurrent respiratory conditions. An oxygen saturation of 89% is less than optimal. A respiratory rate of 16 breaths / minute is in the normal range.

The nurse is caring for a client with an endotracheal tube attached to a mechanical ventilator. The high-pressure alarm sounds, and the nurse assesses the client. The nurse determines that the cause of the alarm is most likely to be due to which complication? 1. A kink in the ventilator circuit 2. A leak in the endotracheal tube cuff 3. Displacement of the endotracheal tube 4. A disconnection of the ventilator tubing

1. A kink in the ventilator circuit **A high pressure alarm occurs if the amount of pressure needed for ventilating a client exceeds the present amount. Causes of high pressure alarm activation include excess secretions; mucous plugs; the client biting on the endotracheal tube; knicks in the ventilator tubing; and the client coughing, gagging, or attempting to talk. **The remaining options would trigger the low pressure alarm.

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse would expect to note which finding? 1. Rhythmic respirations with periods of apnea 2. Regular rapid and deep, sustained respirations 3. Totally irregular respiration in rhythm and depth 4. Irregular respirations with pauses at the end of inspiration and expiration

1. Rhythmic respirations with periods of apnea **Cheyne Stokes respirations are rhythmic respirations with periods of apnea and can indicate a metabolic dysfunction in the cerebral hemisphere os basal ganglia. **Neurogenic hyperventilation is a regular rapid and deep, sustained respiration that can indicate a dysfunction in the low midbrain and middle pons. Ataxic respirations are totally irregular in rhythm and depth and indicate a dysfunction in the medulla. Apneustic respirations are irregular respirations with pauses at the end of inspiration and expiration and can indicate a dysfunction in the middle or caudal pons.

The nurse is told that a client will have an arterial blood gas sample drawn on room air. The nurse is asked to complete the laboratory requisition. The nurse documents on the requisition that the client was receiving how much oxygen for the procedure? 1. 16% 2. 21% 3. 30% 4. 40%

2. 21% **Room air contains 21% oxygen. **It is not possible to give a client 16% oxygen because that is less than room air. The other options specify oxygen amounts that commonly are used to supplement clients who are experiencing respiratory difficulty.

An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client? 1. Face tent 2. Venturi mask 3. Aerosol mask 4. Tracheostomy collar

2. Venturi mask **The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation such as chronic obstructive pulmonary disease because it delivers a precise oxygen concentration. **The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity.

A health care provider writes a prescription to begin to wean the client from the mechanical ventilator by use of intermittent mandatory ventilation (IMV). The registered nurse determines that the new graduate nurse understands this modality of weaning if which statement is made? 1. "The respiratory rate is decreased gradually until the client can assume the work of breathing without ventilatory assistance." 2. "A T-piece will be attached to the ventilator and provide supplemental oxygen at a concentration that is 10% higher than the ventilator setting." 3. "It will provide pressure support to decrease the workload of breathing and increase the client's ability to initiate spontaneous breathing efforts." 4. "It involves removing the ventilator from the client and closely monitoring the client's ability to breathe spontaneously for a predetermined amount of time."

1. "The respiratory rate is decreased gradually until the client can assume the work of breathing without ventilatory assistance." **IMV/SIMV is one of the methods used for weaning. With this method, the respiratory rate is gradually decreased unit the client assumes all of the work of breathing on their own. This method works exceptionally well in the weaning of clients from short term mechanical ventilation, such as that used in clients who have undergone surgery. The respiratory rate frequently is decreased in increments on an hourly basis until the client is weaned and is ready for extubation.

The nurse enters a client's room with a pulse oximetry machine and tells the client that the primary health care provider (PHCP) has prescribed continuous oxygen saturation readings. The client's facial expression changes to one of apprehension. The nurse can alleviate the client's anxiety by providing which information about pulse oximetry? 1. It is painless and safe. 2. It causes only mild discomfort at the site. 3. It requires insertion of only a very small catheter. 4. It has an alarm to signal dangerous drops in oxygen saturation levels.

1. It is painless and safe. **The nurse would reassure the client that pulse oximetry is a safe, painless, noninvasive method of monitoring oxygen saturation levels. **No discomfort is involved because the oximeter uses a sensor that is attached to a fingertip, a toe, or an earlobe. The machine does have an alarm that will sound in response to interference with monitoring or when the percent of oxygen saturation falls below a preset level.

The nurse is reviewing the ventilator settings on a client with an endotracheal tube attached to mechanical ventilation. The nurse notes that the tidal volume is set at 500 mL. How does the nurse interpret this setting? 1. It is the amount of air delivered with each set breath. 2. It is a breath that has a greater volume than the preset tidal volume. 3. It is the number of breaths that the client will receive per minute by the ventilator. 4. It is the fraction of inspired oxygen (FiO2) that is delivered to the client through the ventilator.

1. It is the amount of air delivered with each set breath. **Tidal volume is the amount of air delivered with each set breath on the mechanical ventilator. A sigh is a breath that has a greater volume than the preset tidal volume. The respiratory rate is the number of breaths to be delivered by the ventilator each minute. The FiO2 delivered to the client is indicated by the FiO2 indicator on the ventilator.

The nurse is caring for a client with a tracheostomy tube attached to a ventilator. The high-pressure alarm sounds on the ventilator. The nurse would plan to perform which action? 1. Suction the client. 2. Evaluate the cuff for a leak. 3. Assess for a disconnection. 4. Notify the respiratory therapist.

1. Suction the client. **When the high pressure alarm sounds on a ventilator, it is most likely because of an obstruction. The obstruction can be caused by the client biting on the tube, kinking of the tubing, or mucous plugging that requires suctioning. **A cuff leak and disconnection would cause the low-pressure alarm to sound. Notifying the respiratory therapist delays necessary treatment.

The nurse is caring for a client who is mechanically ventilated, and the high-pressure ventilator alarm is sounding. The nurse understands that which complications may cause this alarm? Select all that apply. 1. Water or a kink in the tubing 2. Biting on the endotracheal tube 3. Increased secretions in the airway 4. Disconnection or leak in the system 5. The client ceasing spontaneous breathing

1. Water or a kink in the tubing 2. Biting on the endotracheal tube 3. Increased secretions in the airway **Causes of high-pressure ventilator alarms include water or a kink in the tubing, biting on the endotracheal tube, increased secretions in the airway, wheezing or bronchospasm, displacement of the endotracheal tube, or the client fighting the ventilator. **A disconnection or leak in the system and the client ceasing to spontaneously breathe are causes of a low pressure ventilator alarm.

The nurse is caring for a client who is mechanically ventilated and is monitoring for complications of mechanical ventilation. Which assessment finding, if noted by the nurse, indicates the need for follow-up? 1. Muscle weakness in the arms and legs 2. A temperature of 98.6° F (37° C), decreased from 99.0° F (37.2° C) 3. A blood pressure of 90/60 mm Hg, decreased from 112/78 mm Hg 4. A heart rate of 80 beats/minute, decreased from 85 beats/minute

3. A blood pressure of 90/60 mm Hg, decreased from 112/78 mm Hg **Complications of mechanical ventilation include the following: hypotension caused by application of positive pressure, which increases intrathoracic pressure and inhibits blood return to the heart; pneumothorax or subcutaneous emphysema as a result of positive pressure; gastrointestinal alterations such as stress ulcers; malnutrition if nutrition is not maintained; infections; muscular deconditioning; and ventilator dependence or inability to wean. Some muscle weakness is expected. The other options are normal assessment findings.

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds would the nurse expect to hear when performing a respiratory assessment on this client? 1. Stridor 2. Crackles 3. Wheezes 4. Diminished

3. Wheezes **Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and weezing. Wheezes are described as high pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. ** Stridor is a harsh sound noted with an upper airway obstruction and often signals a life-threatening emergency. Crackles are produced by air passing over retained airway secretions or fluid, or the sudden opening of collapsed airways. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring.

The low-exhaled volume alarm sounds on a mechanical ventilator of a client with an endotracheal tube. The nurse determines that the cause for alarm activation may be which complication? 1. Excessive secretions 2. Kinks in the ventilator tubing 3. The presence of a mucous plug 4. Disconnection of the ventilator tube

4. Disconnection of the ventilator tube **The low exhaled volume alarm will sound if the client does not receive the present tidal volume.Possible causes of inadequate tidal volume include disconnection of the ventilator tubing from the artificial airway, a leak in the endotracheal or tracheostomy cuff, and disconnection at any location of the ventilator parts. **The other options about cause the high pressure alarm to sounds.