Chapter 21: Respiratory Care Modalities
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? A.) Endotracheal suctioning B.) Encouragement of coughing C.) Use of a cooling blanket D.) Incentive spirometry
Answer: A.) Endotracheal suctioning
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? A.) PaO2 B.) pH C.) PCO2 D.) HCO3
Answer: A.) PaO2
The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated? A.) Deflating the cuff before removing the tube B.) Routinely deflating the cuff C.) Checking the cuff pressure every 6 to 8 hours D.) Ensuring that humidified oxygen is always introduced through the tube
Answer: B.) Routinely deflating the cuff
After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must: A.) report fluctuations in the water-seal chamber. B.) clamp the chest tube once every shift. C.) encourage coughing and deep breathing. D.) milk the chest tube every 2 hours.
Answer: C.) encourage coughing and deep breathing. Rationale: When caring for a client who's recovering from a thoracotomy, the nurse should encourage coughing and deep breathing to prevent pneumonia. Fluctuations in the water-seal chamber are normal. Clamping the chest tube could cause a tension pneumothorax. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage.
A nurse is caring for a client with COPD who needs teaching on pursed-lip breathing. Place the steps in order in which the nurse will instruct the client.
Answer: "Inhale through your nose." "Slowly count to 3." "Exhale slowly through pursed lips." "Slowly count to 7."
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? A.) The patient is hypoxic from suctioning. B.) The patient is having a stress reaction. C.) The patient is having a myocardial infarction. D.) The patient is in a hypermetabolic state.
Answer: A.) The patient is hypoxic from suctioning. Rationale: 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.
What assessment method would the nurse use to determine the areas of the lungs that need draining? A.) Inspection B.) Chest X-ray C.) Arterial blood gas (ABG) levels D.) Auscultation
Answer: D.) Auscultation Rationale: 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.
For a client with an endotracheal (ET) tube, which nursing action is the most important? A.) Auscultating the lungs for bilateral breath sounds B.) Turning the client from side to side every 2 hours C.) Monitoring serial blood gas values every 4 hours D.) Providing frequent oral hygiene
Answer: A.) Auscultating the lungs for bilateral breath sounds
Which is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means? A.) Nasal cannula B.) Venturi mask C.) T-piece D.) Partial-rebreathing mask
Answer: B.) Venturi mask
Which type of ventilator has a preset volume of air to be delivered with each inspiration? A.) Negative pressure B.) Volume cycled C.) Time cycled D.) Pressure cycled
Answer: B.) Volume cycled
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? A.) 45 mm Hg B.) 58 mm Hg C.) 84 mm Hg D.) 120 mm Hg
Answer: C.) 84 mm Hg Rationale; 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 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? A.) Auscultate the lung for adventitious sounds. B.) Have the patient inform the nurse of the need to be suctioned. C.) Assess the CO2 level to determine if the patient requires suctioning. D.) Have the patient cough.
Answer: A.) Auscultate the lung for adventitious sounds.
A client is recovering from thoracic surgery needed to perform a right lower lobectomy. Which of the following is the most likely postoperative nursing intervention? A.) Encourage coughing to mobilize secretions. B.) Restrict intravenous fluids for at least 24 hours. C.) Make sure that a thoracotomy tube is linked to open chest drainage. D.) Assist with positioning the client on the right side.
Answer: A.) Encourage coughing to mobilize secretions. Rationale: The client is encouraged to cough frequently to mobilize secretions. The client will be placed in the semi-Fowler's position. The chest tube is always attached to closed, sealed drainage to re-expand lung tissue and prevent pneumothorax. Restricting IV fluids in a client who is NPO while recovering from surgery would lead to dehydration.
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.) Kinking of the ventilator tubing B.) A disconnected ventilator circuit C.) An ET cuff leak D.) A change in the oxygen concentration without resetting the oxygen level alarm
Answer: A.) Kinking of the ventilator tubing Rationale: 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 circuit 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.
Which oxygen administration device has the advantage of providing a high oxygen concentration? A.) Nonrebreathing mask B.) Venturi mask C.) Catheter D.) Face tent
Answer: A.) Nonrebreathing mask Rationale: The nonrebreathing mask provides high oxygen concentration, but it usually fits poorly. However, if the nonrebreathing mask fits the client snugly and both side exhalation ports have one-way valves, it is possible for the client to receive 100% oxygen, making the nonrebreathing mask a high-flow oxygen system. The Venturi mask provides low levels of supplemental oxygen. The catheter is an inexpensive device that provides a variable fraction of inspired oxygen and may cause gastric distention. A face tent provides a fairly accurate fraction of inspired oxygen but is bulky and uncomfortable. It would not be the device of choice to provide a high oxygen concentration.
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: A.) Symmetry of the client's chest expansion B.) Tracheal cuff pressure set at 30 mm Hg C.) Cool air humidified through the tube D.) A scheduled time for deflation of the tracheal cuff
Answer: A.) Symmetry of the client's chest expansion Rationale: Immediately after intubation, the nurse should check for symmetry of chest expansion. This is one finding that indicates successful endotracheal placement. The tracheal cuff pressure is set between 15 and 20 mm Hg. Routine deflation of the tracheal cuff is not recommended, because the client could then aspirate secretions during the period of deflation. Warm, high, humidified air is administered through the endotracheal tube.
Which is a potential complication of a low pressure in the endotracheal tube cuff? A.) Tracheal bleeding B.) Aspiration pneumonia C.) Tracheal ischemia D.) Pressure necrosis
Answer: B.) Aspiration pneumonia Rationale: 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.
The nurse received a client from the post-anesthesia care unit (PACU) who has a chest tube to a closed drainage system. Report from the PACU nurse included drainage in the chest tube at 80 mL of bloody fluid. Fifteen minutes after transfer from the PACU, the chest tube indicates drainage as pictured. The client is reporting pain at "8" on a scale of 0 to 10. The first action of the nurse is to: A.) Notify the physician. B.) Assess pulse and blood pressure. C.) Administer prescribed pain medication. D.) Lay the client's head to a flat position.
Answer: B.) Assess pulse and blood pressure.
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? A.) Anemic hypoxia B.) Circulatory hypoxia C.) Histotoxic hypoxia D.) Hypoxemic hypoxia
Answer: B.) Circulatory hypoxia RATIONALE: 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. The low blood pressure is consistent with circulatory hypoxia but not consistent with the other options. Anemic hypoxia is a result of decreased effective hemoglobin concentration. Histotoxic hypoxia occurs when a toxic substance interferes with the ability of tissues to use available oxygen. Hypoxemic hypoxia results from a low level of oxygen in the blood.
A nurse is planning care for a client after a tracheostomy. One of the client's goals is to overcome verbal communication impairment. Which intervention should the nurse include in the care plan? A.) Make an effort to read the client's lips to foster communication. B.) Encourage the client's communication attempts by allowing him time to select or write words. C.) Answer questions for the client to reduce his frustration. D.) Avoid using a tracheostomy plug because it blocks the airway.
Answer: B.) Encourage the client's communication attempts by allowing him time to select or write words.
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? A.) Promote more efficient and controlled ventilation and to decrease the work of breathing B.) Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing C.) Promote the strengthening of the client's diaphragm D.) Promote the client's ability to take in oxygen
Answer: B.) Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing Rationale: Pursed-lip breathing, which improves oxygen transport, helps induce a slow, deep breathing pattern and assists the client to control breathing, even during periods of stress. This type of breathing helps prevent airway collapse secondary to loss of lung elasticity in emphysema.
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? A.) Oxygen-induced hypoventilation B.) Oxygen toxicity C.) Oxygen-induced atelectasis D.) Hypoxia
Answer: B.) Oxygen toxicity Rationale: 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.
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? A.) Check for an apical pulse. B.) Suction the client's artificial airway. C.) Increase the oxygen percentage. D.) Ventilate the client with a handheld mechanical ventilator.
Answer: B.) Suction the client's artificial airway. Rationale: 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.
When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for how long? A.) no longer than 5 seconds B.) no longer than 10 seconds C.) no longer than 20 seconds D.) no longer than 30 seconds
Answer: B.) no longer than 10 seconds Rationale: 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 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: A.) pressure support ventilation (PSV). B.) synchronized intermittent mandatory ventilation (SIMV). C.) assist-control (AC) ventilation. D.) continuous positive airway pressure (CPAP).
Answer: B.) synchronized intermittent mandatory ventilation (SIMV). Rationale: In SIMV mode, the ventilator delivers a preset number of breaths at a preset tidal volume. The client can breathe on his own in between the breaths delivered by the ventilator. In PSV, a pressure plateau is added to the ventilator to prevent the airway pressure from falling beneath a preset level. In AC ventilation, the ventilator delivers a preset number of breaths at a preset tidal volume and any breaths that the client takes on his own are assisted by the ventilator so they reach the preset tidal volume. In CPAP, the ventilator provides only positive airway pressure; it doesn't provide any breaths to the client.
A client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. The client is placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. What setting would be the best maximum FIO2 setting? A.) 0.21 B.) 0.35 C.) 0.5 D.) 0.7
Answer: C.) 0.5 Rationale: An FIO2 greater than 0.5 for as little as 16 to 24 hours can be toxic and can lead to decreased gas diffusion and surfactant activity. Clients with respiratory disorders are given oxygen therapy only to increase the partial pressure of oxygen (PaO2) back to the patient's normal baseline, which may vary from 60 to 95 mm Hg. In terms of the oxyhemoglobin dissociation curve, arterial hemoglobin at these levels is 80% to 98% saturated with oxygen; higher FiO2 flow values add no further significant amounts of oxygen to the red blood cells or plasma. Instead of helping, increased amounts of oxygen may produce toxic effects on the lungs and central nervous system or may depress ventilation. The ideal oxygen source is room air FIO2 0.21.
A patient is to receive an oxygen concentration of 70%. What is the best way for the nurse to deliver this concentration? A.) A nasal cannula B.) An oropharyngeal catheter C.) A partial rebreathing mask D.) A Venturi mask
Answer: C.) A partial rebreathing mask Rationale: Partial rebreathing masks have a reservoir bag that must remain inflated during both inspiration and expiration. The nurse adjusts the oxygen flow to ensure that the bag does not collapse during inhalation. A high concentration of oxygen (50% to 75%) can be delivered because both the mask and the bag serve as reservoirs for oxygen. The other devices listed cannot deliver oxygen at such a high concentration.
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 A.) Consults with the physician about removing the client from the ventilator B.) Changes the setting on the ventilator to increase breaths to 14 per minute C.) Continues assessing the client's respiratory status frequently D.) Contacts the respiratory therapy department to report the ventilator is malfunctioning
Answer: C.) Continues assessing the client's respiratory status frequently
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? A.) Surgery to remove the tonsils and adenoids B.) Medications to assist the patient with sleep at night C.) Continuous positive airway pressure (CPAP) D.) Bi-level positive airway pressure (BiPAP)
Answer: C.) Continuous positive airway pressure (CPAP) Rationale: 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.
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? A.) pH B.) Bicarbonate (HCO3-) C.) Partial pressure of arterial oxygen (PaO2) D.) Partial pressure of arterial carbon dioxide (PaCO2)
Answer: C.) Partial pressure of arterial oxygen (PaO2) Rationale: 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 nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? A.) The system is functioning normally. B.) The client has a pneumothorax. C.) The system has an air leak. D.) The chest tube is obstructed.
Answer: C.) The system has an air leak. Rationale: 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.
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? A.) Have the patient lie in a supine position during the use of the spirometer. B.) Encourage the patient to try to stop coughing during and after using the spirometer. C.) Inform the patient that using the spirometer is not necessary if the patient is experiencing pain. D.) Encourage the patient to take approximately 10 breaths per hour, while awake.
Answer: D.) Encourage the patient to take approximately 10 breaths per hour, while awake.
A patient with emphysema is placed on continuous oxygen at 2 L/min at home. Why is it important for the nurse to educate the patient and family that they must have No Smoking signs placed on the doors? A.) Oxygen is combustible. B.) Oxygen is explosive. C.) Oxygen prevents the dispersion of smoke particles. D.) Oxygen supports combustion.
Answer: D.) Oxygen supports combustion.
The nurse is preparing to perform tracheostomy care for a client with a newly inserted tracheostomy tube. Which action, if performed by the nurse, indicates the need for further review of the procedure? A.) Cleans an infected wound and the plate with a sterile cotton tip moistened with hydrogen peroxide B.) Dries and reinserts the inner cannula or replaces it with a new disposable inner cannula C.) Puts on clean gloves; removes and discards the soiled dressing in a biohazard container D.) Places clean tracheostomy ties then removes soiled ties after the new ties are in place without a second nurse assisting
Answer: D.) Places clean tracheostomy ties then removes soiled ties after the new ties are in place without a second nurse assisting Rationale: For a new tracheostomy, two people should assist with tie changes to help make sure the new tracheostomy is not dislodged. A dislodged tracheostomy is a medical emergency. The other actions, if performed by the nurse during tracheostomy care, are correct. The wound and plate should be cleaned with sterile cotton-tipped applicators moistened with saline or sterile water or with hydrogen peroxide if infection is present. The inner cannula should be dried before reinsertion or if a disposable is being used, a new disposable cannula should be reinserted. The nurse should put on clean gloves and discard the soiled dressing in a biohazard container.
A client undergoes a tracheostomy after many failed attempts at weaning him from a mechanical ventilator. Two days after tracheostomy, while the client is being weaned, the nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first? A.) Call the physician. B.) Remove the malfunctioning cuff. C.) Add more air to the cuff. D.) Suction the client, withdraw residual air from the cuff, and reinflate it.
Answer: D.) Suction the client, withdraw residual air from the cuff, and reinflate it. Rationale: After discovering an air leak, the nurse first should check for insufficient air in the cuff — the most common cause of a cuff air leak. To do this, the nurse should suction the client, withdraw all residual air from the cuff, and then reinflate the cuff to prevent overinflation and possible cuff rupture. The nurse should notify the physician only after determining that the air leak can't be corrected by nursing interventions, or if the client develops acute respiratory distress. The tracheostomy tube cuff can't be removed and replaced with a new one without changing the tracheostomy tube; also, removing the cuff would create a total air leak, which isn't correctable. Adding more air to the cuff without first removing residual air may cause cuff rupture.