Chapter 21 Respiratory Care Modalities
A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned? Have the patient inform the nurse of the need to be suctioned. Auscultate the lung for adventitious sounds. Assess the CO2 level to determine if the patient requires suctioning. Have the patient cough.
Auscultate the lung for adventitious sounds. Explanation: When a tracheostomy or endotracheal tube is in place, it is usually necessary to suction the patient's secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are obviously present. Unnecessary suctioning can initiate bronchospasm and cause mechanical trauma to the tracheal mucosa.
What assessment method would the nurse use to determine the areas of the lungs that need draining? Inspection Auscultation Arterial blood gas (ABG) levels Chest X-ray
Auscultation Explanation: The nurse should assess breath sounds before doing postural drainage to determine the areas that need draining. Inspection, chest X-rays, and ABG levels are all assessment parameters that give good information about respiratory function but aren't necessary to determine lung areas requiring postural drainage.
The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient? The patient is having a myocardial infarction. The patient is hypoxic from suctioning. The patient is having a stress reaction. The patient is in a hypermetabolic state.
The patient is hypoxic from suctioning. Explanation: Apply suction while withdrawing and gently rotating the catheter 360 degrees (no longer than 10-15 seconds). Prolonged suctioning may result in hypoxia and dysrhythmias, leading to cardiac arrest.
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? 84 mm Hg 58 mm Hg 45 mm Hg 120 mm Hg
84 mm Hg Explanation: In general, clients with respiratory conditions are given oxygen therapy only to increase the arterial oxygen pressure (PaO2) back to the client's normal baseline, which may vary from 60 to 95 mm Hg.
A client has a sucking stab wound to the chest. Which action should the nurse take first? Draw blood for a hematocrit and hemoglobin level. Prepare to start an I.V. line. Prepare a chest tube insertion tray. Apply a dressing over the wound and tape it on three sides.
Apply a dressing over the wound and tape it on three sides. Explanation: The nurse should immediately apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line.
Which is a potential complication of a low pressure in the endotracheal tube cuff? Pressure necrosis Tracheal bleeding Aspiration pneumonia Tracheal ischemia
Aspiration pneumonia Explanation: Low pressure in the cuff can increase the risk for aspiration pneumonia. High pressure in the cuff can cause tracheal bleeding, ischemia, and pressure necrosis.
Which is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means? T-piece Nasal cannula Partial-rebreathing mask Venturi mask
Auscultation Explanation: The nurse should assess breath sounds before doing postural drainage to determine the areas that need draining. Inspection, chest X-rays, and ABG levels are all assessment parameters that give good information about respiratory function but aren't necessary to determine lung areas requiring postural drainage.
A thoracentesis is performed to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes. What does serous fluid indicate? Infection Emphysema Trauma Cancer
Cancer Explanation: A thoracentesis may be performed to obtain a sample of pleural fluid or to biopsy a specimen from the pleural wall for diagnostic purposes. Serous fluid may be associated with cancer, inflammatory conditions, or heart failure. Blood fluid typically suggests trauma. Purulent fluid is diagnostic for infection. Complications that may follow a thoracentesis include pneumothorax and subcutaneous emphysema.
The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying? Histotoxic hypoxia Anemic hypoxia Circulatory hypoxia Hypoxemic hypoxia
Circulatory hypoxia Explanation: Given the vital signs, this client appears to be in shock. Circulatory hypoxia results from inadequate capillary circulation and may be caused by decreased cardiac output, local vascular obstruction, low-flow states such as shock, or cardiac arrest. Although tissue partial pressure of oxygen (PO2) is reduced, arterial oxygen (PaO2) remains normal. Circulatory hypoxia is corrected by identifying and treating the underlying cause.
A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse Consults with the physician about removing the client from the ventilator Continues assessing the client's respiratory status frequently Changes the setting on the ventilator to increase breaths to 14 per minute Contacts the respiratory therapy department to report the ventilator is malfunctioning
Continues assessing the client's respiratory status frequently Explanation: The SIMV setting on a ventilator allows the client to breathe spontaneously with no assistance from the ventilator for those extra breaths. Data in the stem suggest that the ventilator is working correctly. The nurse would continue making frequent respiratory assessments of the client. There are not sufficient data to suggest the client could be removed from the ventilator. There is no reason to increase the ventilator's setting to 14 breaths per minute or to contact respiratory therapy to report the machine is not working properly.
A client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this client? Bi-level positive airway pressure (BiPAP) Medications to assist the patient with sleep at night Surgery to remove the tonsils and adenoids Continuous positive airway pressure (CPAP)
Continuous positive airway pressure (CPAP) Explanation: CPAP provides positive pressure to the airways throughout the respiratory cycle. Although it can be used as an adjunct to mechanical ventilation with a cuffed endotracheal tube or tracheostomy tube to open the alveoli, it is also used with a leak-proof mask to keep alveoli open, thereby preventing respiratory failure. CPAP is the most effective treatment for obstructive sleep apnea because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. CPAP is used for clients who can breathe independently. BiPAP is most often used for clients who require ventilatory assistance at night, such as those with severe COPD or sleep apnea.
The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated? Routinely deflating the cuff Ensuring that humidified oxygen is always introduced through the tube Deflating the cuff before removing the tube Checking the cuff pressure every 6 to 8 hours
Routinely deflating the cuff Explanation: Routine cuff deflation is not recommended because of the increased risk for aspiration and hypoxia. The cuff is deflated before the ET is removed. Cuff pressures should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tube.
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. Explanation: The patient should be instructed to perform the procedure approximately 10 times in succession, repeating the 10 breaths with the spirometer each hour during waking hours. The patient should assume a semi-Fowler's position or an upright position before initiating therapy, not be supine. Coughing during and after each session is encouraged, not discouraged. The patient should Splint the incision when coughing postoperatively. The patient should still use the spirometer when in pain.
A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? Incentive spirometry Endotracheal suctioning Use of a cooling blanket Encouragement of coughing
Endotracheal suctioning Explanation: Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.
A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition? Delirium Hypoxia Semiconsciousness Hyperventilation
Hypoxia Explanation: As the respiratory center in the brain becomes depressed, hypoxia occurs, producing wheezing, bradycardia, and a decreased respiratory rate. Delirium is a state of mental confusion characterized by disorientation to time and place. Hyperventilation (respiratory rate greater than that metabolically necessary for gas exchange) is marked by an increased respiratory rate or tidal volume, or both. Semiconsciousness is a state of impaired consciousness characterized by limited motor and verbal responses and decreased orientation.
The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique? Perform this measure with the client once a day. Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes. Administer bronchodilators and mucolytic agents following the sequence. Use aerosol sprays to deodorize the client's environment after postural drainage.
Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes. Explanation: 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 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 Water-seal chest drainage set-up Manual resuscitation bag
Manual resuscitation bag Explanation: The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit at the bedside isn't necessary. Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate the effectiveness of ventilation, this equipment is less important than the manual resuscitation bag.
For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan? Stripping the chest tube every hour Measuring and documenting the drainage in the collection chamber Keeping the collection chamber at chest level Maintaining continuous bubbling in the water-seal chamber
Measuring and documenting the drainage in the collection chamber Explanation: The nurse should regularly measure and document the amount of chest tube drainage to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected. The nurse should keep the collection chamber below chest level to allow fluids to drain into it. The nurse shouldn't strip chest tubes because doing so may traumatize the tissue or dislodge the tube.
A client who is undergoing thoracic surgery has a nursing diagnosis of "Impaired gas exchange related to lung impairment and surgery" on the nursing care plan. Which of the following nursing interventions would be appropriately aligned with this nursing diagnosis? Select all that apply. Monitor pulmonary status as directed and needed. Regularly assess the client's vital signs every 2 to 4 hours. Encourage deep breathing exercises. Request order for patient-controlled analgesia pump Monitor and record hourly intake and output.
Monitor pulmonary status as directed and needed. Regularly assess the client's vital signs every 2 to 4 hours. Encourage deep breathing exercises. Explanation: Interventions to improve the client's gas exchange include monitoring pulmonary status as directed and needed, assessing vital signs every 2 to 4 hours, and encouraging deep breathing exercises. The nurse would request an order for patient-controlled analgesia if appropriate for the client, but that would be an intervention related to post-surgical pain, not impaired gas exchange. Monitoring and recording hourly intake and output are essential interventions for ensuring appropriate fluid balance but not directly related to impaired gas exchange.
A client has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the client complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect? Hypoxia Oxygen-induced atelectasis Oxygen toxicity Oxygen-induced hypoventilation
Oxygen toxicity Explanation: Oxygen toxicity may occur when too high a concentration of oxygen (greater than 50%) is administered for an extended period (longer than 48 hours) (Urden, Stacy, & Lough, 2014). Signs and symptoms of oxygen toxicity include substernal discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxemia, alveolar atelectasis, and alveolar infiltrates evident on chest x-rays.
The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia? PaO2 pH HCO3 PCO2
PaO2 Explanation: Hypoxemic hypoxia, or hypoxemia, is a decreased oxygen level in the blood (PaO2) resulting in decreased oxygen diffusion into the tissues.
The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia? pH HCO3 PaO2 PCO2
PaO2 Explanation: Hypoxemic hypoxia, or hypoxemia, is a decreased oxygen level in the blood (PaO2) resulting in decreased oxygen diffusion into the tissues.
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? pH Bicarbonate (HCO3-) Partial pressure of arterial carbon dioxide (PaCO2) Partial pressure of arterial oxygen (PaO2)
Partial pressure of arterial oxygen (PaO2) Explanation: The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3-, and PaCO2
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? Check for an apical pulse. Suction the client's artificial airway. Increase the oxygen percentage. Ventilate the client with a handheld mechanical ventilator.
Suction the client's artificial airway. Explanation: A high-pressure alarm on a continuous mechanical ventilator indicates an obstruction in the flow of gas from the machine to the client. The nurse should suction the client's artificial airway to remove respiratory secretions that could be causing the obstruction. The sounding of a ventilator alarm has no relationship to the apical pulse. Increasing the oxygen percentage and ventilating with a handheld mechanical ventilator wouldn't correct the airflow blockage
A client is prescribed postural drainage because secretions are accumulating in the upper lobes of the lungs. The nurse instructs the client to: Take prescribed albuterol (Ventolin) before performing postural drainage. Lay in bed with the head on a pillow. Perform drainage 1 hour after meals. Hold each position for 5 minutes.
Take prescribed albuterol (Ventolin) before performing postural drainage. Explanation: When a client is to perform postural drainage, the nurse should instruct the client to use the prescribed bronchodilator (e.g., albuterol) first. This will open airways and promote drainage. The client is to perform postural drainage before meals, not after. This will aid in preventing nausea, vomiting, and aspiration. For secretions accumulated in the upper lobes, the client will sit up or even lean forward while sitting. Head on a pillow is not a sufficient increase in height. The client is also to lay in each position for 10 to 15 minutes.
A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? The client has a pneumothorax. The system has an air leak. The system is functioning normally. The chest tube is obstructed.
The system has an air leak. Explanation: Constant bubbling in the water-seal chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the fluid would stop fluctuating in the water-seal chamber.
For a client with an endotracheal (ET) tube, which nursing action is the most important? Auscultating the lungs for bilateral breath sounds Monitoring serial blood gas values every 4 hours Turning the client from side to side every 2 hours Providing frequent oral hygiene
Venturi mask Explanation: The Venturi mask is the most reliable and accurate method for delivering a precise concentration of oxygen through noninvasive means. The mask is constructed in a way that allows a constant flow of room air blended with a fixed flow of oxygen. Nasal cannula, T-piece, and partial-rebreathing masks are not the most reliable and accurate methods of oxygen administration.
Which type of ventilator has a preset volume of air to be delivered with each inspiration? Pressure cycled Time cycled Volume cycled Negative pressure
Volume cycled Explanation: With volume-cycled ventilation, the volume of air to be delivered with each inspiration is preset. Negative-pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a preset pressure, and then cycles off, and expiration occurs passively.
The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for: Symmetry of the client's chest expansion Tracheal cuff pressure set at 30 mm Hg A scheduled time for deflation of the tracheal cuff Cool air humidified through the tube
Volume-controlled Explanation: With volume-controlled ventilation, the volume of air to be delivered with each inspiration is preset. Negative-pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a preset pressure, and then cycles off, and expiration occurs passively.
Which type of ventilator has a preset volume of air to be delivered with each inspiration? Time-cycled Volume-controlled Pressure-cycled Negative-pressure
Volume-controlled Explanation: With volume-controlled ventilation, the volume of air to be delivered with each inspiration is preset. Negative-pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a preset pressure, and then cycles off, and expiration occurs passively.
After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes? Suction control chamber Air-leak chamber Water-seal chamber Collection chamber
Water-seal chamber Explanation: Fluctuations in the water-seal compartment are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respirations. The air-leak meter — not chamber — detects air leaking from the pleural space. The collection chamber connects the chest tube from the client to the system. Drainage from the tube drains into and collects in a series of calibrated columns in this chamber. The suction control chamber provides the suction, which can be controlled to provide negative pressure to the chest.
A nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is: preventing him from developing an infection. helping him communicate. keeping his airway patent. encouraging him to perform activities of daily living (ADLs).
keeping his airway patent. Explanation: Maintaining a patent airway is the most basic and critical human need. Helping the client communicate, encouraging him to perform ADLs, and preventing him from developing an infection are important to the client's well-being but not as important as having sufficient oxygen to breathe.
When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for how long? no longer than 5 seconds no longer than 10 seconds no longer than 20 seconds no longer than 30 seconds
no longer than 10 seconds Explanation: In general, the nurse should apply suction no longer than 10. Applying suction for longer is hazardous and may result in the development of hypoxia, which can lead to dysrhythmias and, ultimately, cardiac arrest. Applying suction for 0-5 seconds would provide too little time for effective suctioning of secretions.
A client who underwent thoracic surgery to remove a lung tumor had a chest tube placed anteriorly. The surgical team places this catheter to: administer IV medication. ventilate the client. remove air from the pleural space. remove fluid from the lungs.
remove air from the pleural space. Explanation: After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand. A catheter placed in the pleural space provides a drainage route through a closed or underwater-seal drainage system to remove air. Sometimes two chest catheters are placed following thoracic surgery: one anteriorly and one posteriorly. The anterior catheter removes air; the posterior catheter removes fluid.
A nurse is caring for a client who was intubated because of respiratory failure. The client is now receiving mechanical ventilation with a preset tidal volume and number of breaths each minute. The client has the ability to breathe spontaneously between the ventilator breaths with no ventilator assistance. The nurse should document the ventilator setting as: synchronized intermittent mandatory ventilation (SIMV). continuous positive airway pressure (CPAP). assist-control (AC) ventilation. pressure support ventilation (PSV).
synchronized intermittent mandatory ventilation (SIMV). Explanation: Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 528.
