AHII - Exam 3 (Respiratory Module)
Suction is controlled by water level, usually ___ cm H2O
-20cm H2O (MD order)
Fill water seal chamber to the ___ cm level with sterile water.
2 cm
Suction level acceptable for thoracic drainage___ to ___ cm
5-40 cm
Pericardiocentesis
A needle puncture into the space around the heart (typically to remove fluid)
Thoracotomy
A procedure in which the chest cavity is cut open
A patient is placed on volume-cycled ventilation. The nurse plans care for this client based on which characteristic of this method of ventilation? A. Delivers a set volume, which will help overcome the client's airway resistance changes. B. The mechanism by which the phase of the breath switches from inspiration to expiration. C. Provides a consistent tidal volume. D. Delivers a preset volume of gas to the lungs to generate high pressures.
A. Delivers a set volume, which will help overcome the client's airway resistance changes. Volume- cycled ventilation delivers a preset volume of gas to the lungs, making volume constant therefore, overcoming the changes in lung compliance and airway resistance.
What are strategies to prevent Ventilator-associated Pneumonia? (select all that apply) A. Oral care every 4 hours, B. HOB elevated 30-45 degrees unless contraindicated by the patient's condition C. HOB elevated 10-15 degrees, unless contraindicated by the patient's condition D. Allow family to suction patient as needed to remove secretions
A. Oral care Q4h B. HOB elevated 30-45 degrees unless contraindicated by patients condition
CDU =
Chest Drainage Unit
The low tidal volume alarm on a client's ventilator keeps sounding. What is the nurse's first action? A) Manually ventilate the client. B) Put air into the endotracheal tube cuff. C) Check ventilator connections. D) Call the physician.
C) Check ventilator connections Ventilator connections should be check initially and loose connections or disconnections should be fixed. If there is no immediate problem found, the client should be manually ventilated and another person should check the ventilator connections. Test Plan: Management of care
The client is on CPAP for weaning from a mechanical ventilator. Assessment reveals a respiratory rate of 32/min, oxygen saturation of 88 percent, and use of accessory muscles. What should the nurse anticipate will occur? A. The FiO2 will be increased B. Weaning will continue C. The client will be placed back on full ventilatory support D. The client will be extubated
C. The client will be placed back on full ventilatory support Weaning should be discontinued, as the client is showing signs of intolerance.
Closed pneumothorax
Chest wall intact - Rupture of the lung & visceral pleura (or airway) allows air into pleural space
Tension Pneumothorax
Closed (chest wall intact) - Air enters pleural space from the lung/airway & has no way to leave - Pressure continues to build & is then transmitted to mediastinum (heart & great vessels) Mediastinal Shift - occurs when pressure gets so high it pushed heart & great vessels into the UNAFFECTED SIDE of chest - cardiovascular collapse Most dangerous when pt receiving positive pressure ventilation (air forced into chest under pressure)
Chest Tube
Conditions Requiring chest drainage: - Pneumothorax - Hemothorax - Pleural Effusion - Tension pneumo valsalva below level of chest crepitus (subcutaneous emphysema) Milking/stripping (clot suspects)
A client has just been intubated for placement on a mechanical ventilator. What is the first assessment of the tube placement? A) Chest X-Ray B) Auscultation of breath sounds C) Pulse oximetry reading of 95% D) End tidal CO2 monitoring
D) End tidal CO2 monitoring End tidal CO2 monitoring is the first intervention to determine if the endotracheal tube is in place, but a chest x-ray is still needed to confirm proper placement.
A Client has been intubated and placed on a volume-cycled mechanical ventilator. The nurse carefully assess the client for findings associated with a risk associated with this type of ventilator. What is the risk? A. Hypoventilation B. Hypercapnia C. Respiratory acidosis D. Barotrauma
D. Barotrauma The volume-cycled ventilator has the potential to increase pressure in order to deliver the set volume. barotrauma is a risk associated with this form of mechanical ventilation.
Orthopnea
Means you have to be in the upright position to breath well (difficulty breathing lying down)
Capnography
Measurement of carbon dioxide levels
Open pneumothorax
Opening in chest wall (with or w/o lung puncture)
A nurse in the ICU is caring for a client that has been ventilated for 2 weeks due to Acute Respiratory Distress Syndrome (ARDS). The client's FiO2 has been at 60% for the last 48 hours. What is the nurse's immediate priority concern at this time?
Oxygen toxicity Clients with ARDS require high levels of oxygen. Levels above 50% FiO2 for prolonged periods of time can cause oxygen toxicity. This is why the SpO2 goal for these clients tends to be approximately 92-94%. If a client has an SpO2 of 100%, the FiO2 needs to be decreased!
The nurse is caring for a client on bed rest in the supine position. The nurse obtains vital signs and notes that the client has an oxygen saturation of 89% on room air. Which of the following actions should the nurse take next?
Raise the head of the bed and re-check the oxygen saturation Raising the head of the bed and encouraging the client to cough and deep breathe can increase the client's oxygen saturation. The nurse should implement these simple interventions, then check the pulse oximeter, possibly on another finger. If the O2 saturation does not improve, the nurse can start oxygen therapy to titrate the oxygen level to >90%. If there is not an order to titrate oxygen, the nurse would contact the provider for an order, or involve the respiratory therapist if availabl
Hemoptysis
Spitting up blood
The nurse is caring for a client with a chest tube. The nurse will refrain from clamping the chest tube because which of the following could happen? Tension pneumothorax Airway constriction Barrel chest Pneumonia
Tension pneumothorax Clamping a chest tube can cause a tension pneumothorax, because it becomes a one-way valve for air to enter the pleural space, but the air cannot escape because the tube is clamped. The trachea will deviate away from the affected side in this situation, and the client will present with chest pain, dyspnea, hypoxia and hypotension.
A nurse is caring for a client who uses supplemental oxygen by nasal cannula. The provider left the following order: "O2 by nasal cannula to keep saturations >95% and PaO2 >80 mmHg." In this situation, which describes the PaO2?
The amount of dissolved oxygen in the blood When studying arterial blood gas measurements, it is important to understand the different components of the test and what they mean. The PaO2 describes the partial pressure of oxygen in the blood sample and is a measure of appropriate oxygenation of the blood. In most clients, the PaO2 should be between 80 and 100 mmHg, which demonstrates adequate oxygenation.
Continuous bubbling indicates _______.
air leak (should only see bubbling when pt coughs/exhales)
Pleural Effusion
Transudate: fluid that passes through a membrane; compared w/an exudate, has fewer cellular elements Exudate: any fluid from the body w/a high concentration of protein, cells, or solid debris Empyema: collection of purulent (pus) fluid in pleural space
Spontaneous Pneumothorax
Weak area on the lung ruptures, allowing air to leak into intrapleural space Ex) Pulmonary Bleb (blister) **NOT CAUSED BY INJURY
A nurse is caring for a client after having a tracheostomy placed. Which of the following are appropriate nursing interventions for the client with a tracheostomy? a) Hyperoxygenate the client prior to suctioning b) Ensure that the cuff is deflated during meals c) Monitor arterial blood gases rather than pulse oximetry d)Insert the plug into the tracheostomy tube prior to removing the inner cannula
a) Hyperoxygenate the client prior to suctioning When a client has a tracheostomy tube, it will need to be suctioned regularly to prevent airflow occlusion. Each time the tracheostomy is suctioned, the client's oxygen level will drop because they are unable to take a breath. It is important to hyperoxygenate the client prior to suctioning the tracheostomy tube.
A nurse is caring for a client with a chest tube. He notes that the dressing around the client's tube insertion site is wet and there is some crepitus with mild palpation. Which actions by the nurse are most appropriate in this situation? (select all that apply) a) Keep the tubing below the level of the insertion site b) Notify the provider to evaluate the level of suction c) Prepare for replacement of the tube d) Gently milk the tubing to remove clots, if present e) Remove the tube and place an occlusive dressing over the site
a) Keep the tubing below the level of the insertion site b) Notify the provider to evaluate the level of suction c) Prepare for replacement of the tube - The nurse should never remove a chest tube without a provider order. Rather, the provider should be notified to confirm placement and evaluate the level of suction. - To avoid back flow of fluid, the tubing must be kept below the insertion site. - Chest tubing should not be stripped or 'milked' unless a provider specifically orders this. Stripping the tubing rapidly changes the pressure in the pleural space. If clots are present, the nurse can pinch the tubing, hand over hand, until the clots move into the chest drainage unit. - Crepitus indicates subcutaneous emphysema. The tube will need to be replaced to correct the air leak. - Subcutaneous emphysema may develop in a client with a chest tube if air leaks under the skin, causing crepitus and swelling of the face and neck. The nurse should notify the physician right away and prepare to replace the tube.
A client is admitted to the floor after having a tracheostomy placed 72 hrs ago. Which of the following pieces of equipment is the priority to keep at the bedside at all times? a) Obturator b) Clamps c) Inner cannula d) Wrench
a) Obturator The obturator is kept at the bedside at all times in the event of an accidental decannulation. It would be inserted into the tube, then the tube reinserted into the stoma.
A nurse is caring for a client who had a tracheostomy placed 2 days ago. The nurse enters the room and makes the following observations during a safety check. Which of the following observations would be the MOST concerning? a) Oxygen tubing connected directly to flow meter b) Obturator on the bedside table c) Hydrogen peroxide bottle on the counter d) Trach ties are soiled with dried mucus
a) Oxygen tubing connected directly to flow meter Any client who recently received a tracheostomy tube (and oftentimes even chronic tracheostomy clients) should always be receiving humidified oxygen to prevent a mucous plug from forming. If the tubing is connected directly to the flow meter, that means there is no humidifier attached. There should be a water bottle that the oxygen flows through before going to the client in order to humidify the oxygen. The nurse should notify the respiratory therapist to obtain a humidifier for this client.
A nurse is caring for a client who has a chest tube. While turning the client in bed, the tube is accidentally removed. Which of the following should be the nurse's FIRST response? a) Place a gloved hand over the site b) Turn the client so that the affected side is up c) Place the tip of the catheter near the opening and secure it d) Tell the client to stay still while you go to retrieve an occlussive dressing to cover the site
a) Place a gloved hand over the site If a client's chest tube becomes dislodged and is pulled out, the nurse should immediately cover the site with an occlusive dressing and tape. If these supplies are not immediately available, the nurse should cover the site with a gloved hand, stay with the client and call for help. Occluding the site with dressing or manually acts as a one-way valve to prevent the development of a tension pneumothorax until the condition can be treated by the provider.
The nurse is caring for a client who has been brought to the ED for an asthma exacerbation. Which of the following would NOT be an expected finding when completing a comprehensive respiratory assessment of this client? a) Tachypnea b) Cheyne-Stokes respirations c) Wheezes d) Diminished breath sounds
b) Cheyne-Stokes respirations This is an abnormal respiratory pattern with periods of apnea. It is not an expected clinical finding in a client experiencing an acute asthma exacerbation. All other assessment findings would be expected with this clinical picture.
A nurse is working in the ED and has just received a client with an asthma exacerbation. Which of the following positions would be the MOST conducive to effective gas exchange for this client? a) Trendelenburg b) High-Fowler's c) Prone d) Dorsal Recumbant
b) High-Fowler's High-Fowler's - client sitting straight upright which would best facilitate breathing and gas exchange in a client with an asthma exacerbation.
A nurse is assessing a client with a chest tube. The nurse notes that the client once had a moderate amount of light yellow drainage coming out of the tube and the drainage is now red. Which action should the nurse perform in response? a) Place the client in supine position with chest tube above the level of the heart b) Notify the healthcare provider c) Chart the amount of drainage noted in the collection chamber d) Immediately clamp the chest tube unit
b) Notify the HCP If the chest tube drainage is greater than 70 to 100 mL/hr, increases suddenly or becomes bright red, the nurse must notify the provider. Chest tube drainage color may vary, but any sudden change in the appearance or consistency of the drainage could indicate hemorrhage which should be immediately reported to the provider.
A nurse has just received report on 4 clients who all have chest tubes in place. Which client is the priority to see first? a) The client with tidaling in the drainage tubing b) The client with continuous bubbling in the drainage chamber c) The client with suction pressure set at -20 cmH2O d) The client whose drainage system is standing on the floor
b) The client with continuous bubbling in the drainage chamber Continuous bubbling in the chamber reflects an air leak, meaning there could be a hole in the tubing or it could be dislodged. This client is the priority to be seen first. Note - a client with a pneumothorax will have bubbling in the chamber during breathing, which is a normal, expected finding. But it will fluctuate with breathing, not be continuous.
A nurse is caring for a client who has a chest tube because of a pneumothorax. The nurse can tell the certified nursing assistant to check which of the following? a) Whether there is increased drainage in the last four hours b) The client's respiratory rate c) Whether the chest tube is tidaling d) The level of the water seal on the chest tube
b) The client's respiratory rate When caring for a client who has a chest tube, the nurse cannot delegate its care to unlicensed assistive personnel due to the assessment required for management. The only measure the certified nursing assistant can perform in this case is to check the client's respiratory rate, as this is part of obtaining vital signs.
A nurse is caring for a client who has a chest tube after a motor vehicle accident. The provider has ordered low suction for the chest tube. Which interventions would the nurse utilize when managing suction on this chest tube? (select all that apply) a) Suction is always at low-intermittent suction with a chest tube, never continuous suction b) The wall suction should be set at > 80 mmHg c) The nurse should notify the provider if there is a sudden increase in drainage d) The apparatus should make a sucking sound at the insertion site e) The nurse should note tidaling when the client breathes
b) The wall suction should be set at > 80 mmHg c) The nurse should notify the provider if there is a sudden increase in drainage e) The nurse should note tidaling when the client breathes "The wall suction should be set at > 80 mmHg", "The nurse should note tidaling when the client breathes" and "The nurse should notify the provider if there is a sudden increase in drainage" are correct. When a wet suction control unit is used, the level of water determines the amount of suction inside the chest cavity. The wall suction should be set at >80 mmHg for a suction level of -20 mmHg. Tidaling in the water-seal chamber means that the client is breathing, and is normal. However, intermittent or continuous bubbling in the water-seal chamber means there is an air leak. The leak should be located and fixed immediately, and the provider needs to be notified if the nurse is unable to find the leak. If there is a large increase in the amount of output from the chest tube, the provider must also be notified right away. "The apparatus should make a sucking sound at the insertion site" is incorrect. If there is a sucking sound at the insertion site, this is a medical emergency and must be addressed immediately. "Suction is always at low-intermittent suction with a chest tube, never continuous suction" is incorrect. While low-intermittent suction is most common, it is not the only suction setting used.
Hematochezia
blood in stool
A nurse is orienting a new graduate nurse on a cardiopulmonary nursing unit, caring for a client with a chest tube. Which of the follow actions by the new graduate nurse requires immediate intervention? a) Coiling the tubing in the bed b) Placing the drainage system below the level of the chest c) Clamping the chest tube d) Connecting suction tubing to the drainage system
c) Clamping the chest tube Clamping the tube of a chest tube creates increased pressure and puts the patient at risk for tension pneumothorax. This is only done in very specific circumstances, and often by an advanced practice provider.
The provider has just ordered for a client to be removed from mechanical ventilation. What is a priority nursing intervention before extubation? a) Administer a 0.9% normal saline bolus of 500 ml b) Apply a non-rebreather mask c) Suction the endotracheal tube d) Increase the Diprivan infusion to 30 mcg/kg/hr
c) Suction the endotracheal tube The endotracheal tube should be suctioned immediately before extubation to prevent aspiration of secretions during extubation.
Which of the following is a common finding in an open pneumothorax? a) A flail chest b) Trachea deviated to the side of the injury c) Trachea deviated to the side opposite the injury d) A sucking sound on inspiration and expiration
d) A sucking sound on inspiration and expiration In an open pneumothorax, there is an open wound to the outside so a sucking sound is heard on inspiration and expiration. a) A flail chest - is associated with blunt trauma to the chest, and is not necessarily associated with an open pneumothorax, since an open pneumothorax is caused by a penetrating injury rather than blunt trauma that is severe enough to break ribs in multiple places. b) Trachea deviated to the side of the injury - In a tension pneumothorax, the trachea can be deviated AWAY from the affected side, but not with an open pneumothorax. This is a late sign of tension pneumothorax, however, so it may not be apparent right away and the absence of trachial deviation should not be used to eliminate the possibility of a tension pneumothorax. c) Trachea deviated to the side opposite the injury - In a tension pneumothorax, the trachea can be deviated AWAY from the affected side, but not with an open pneumothorax. This is a late sign of tension pneumothorax, however, so it may not be apparent right away and the absence of trachial deviation should not be used to eliminate the possibility of a tension pneumothorax.
Which of the following steps should the nurse include as part of tracheostomy suctioning? a) Suction both the nares first and then the stoma b) Avoid suctioning unless the client is unable to cough c) Ask the client to take a deep breath and hold it before suctioning d) Insert the catheter without applying suction until resistance is felt
d) Insert the catheter without applying suction until resistance is felt Tracheal suctioning is an important part of caring for a client with a tracheostomy, as excess secretions can build up and clog the tubing which causes breathing difficulties for the client. With the suction turned off, the nurse should insert the suction catheter until resistance is felt to avoid traumatizing the client's airway.
The nurse is caring for the following clients. Which client should be seen first? a) Thoracotomy, pain 10/10, screaming b) Actively vomiting green bile and food particles c) PRBC's just arrived from blood bank to transfuse, hemoglobin 6.8 mg/dL d) New tracheostomy, on a ventilator, SpO2 88%
d) New tracheostomy, on a ventilator, SpO2 88% A client with a brand new tracheostomy tube that is desatting even on a ventilator may have actually decannulated (meaning the tube may have dislodged). It is imperative to assess this client immediately to ensure the airway is intact and/or to check oxygenation status (might need a higher FiO2).
A nurse is caring for a client with a tracheostomy and notes that the client has gurgling sounds coming from the trach site, is breathing rapidly, and is trying to cough. Which action should the nurse perform first? a) Replace the trach tubing with an ambu-bag and provide two measured breaths b) Check capillary refill in the fingernails c) Assess the client's lung sounds d) Suction the opening and the trach tubing
d) Suction the opening and the trach tubing When a client has a tracheostomy tube obstruction, the nurse may be able to hear or see secretions around the opening. The client may attempt to cough, become restless, and breathe rapidly. The nurse should assist the client to cough and deep breathe, provide suctioning, humidification, and regularly clean the inner cannula to keep the tracheostomy open.
A client is scheduled for a BAL, or bronchoalveolar lavage. What is the best description of this procedure? a) Cleaning out the back of the throat b) Suctioning sputum from the nose c) Washing the skin over the chest d) Washing out of the airways of the lungs
d) Washing out of the airways of the lungs A Bronchoalveolar Lavage (BAL) is washing out the airways, usually using sterile saline & suction
Removing Chest Tube Tube should be pulled at the end of full ___________.
inspiration This prevents air from sucking back into the chest
~Extra Practice~
~Extra Practice~