Chapter 36 Airway Management

an alert client cannot cough up secretions and has gurgling sounds from the mouth. The best action of the nurse is to:

suction the mouth with a Yankauer-tip catheter.

The client has a tracheostomy and is producing copious secretions. Secretions are on the tracheostomy cause. The nurse intervenes Best Buy

inserting the suction catheter 4 to 5 in into the trachea

The nurse is evaluating the effectiveness of therapy for a client who has received inhalation therapy treatments during an asthma attack. Which assessment finding is the best indicator that therapy has been effective?

oxygen saturation is greater than 94%

A nurse is assisting a client with inhalation therapy. What does inhalation therapy administered to a client? Select all that apply.

oxygen, humidification, aerosolized, medications

A nurse is preparing to assist a client with chest physiotherapy. Which of the following materials would the nurse have on hand? Select all that apply.

paper tissues, waterproof container

The sedated client has an oxygen saturation that has dropped to 88%, a respiratory rate of 10 breaths per minute, and gurgling sounds with taking breast. The action of the nurse is to

perform nasopharyngeal suctioning.

A nurse is providing tracheostomy care for a client. After removing the plastic inner cannula, which would the nurse do next?

place the cannula in diluted hydrogen peroxide.

A client with a new tracheostomy is becoming frustrated because of his inability to speak. Which intervention will enhance his ability to communicate?

providing the client with a communication board and keep the call Bell within reach.

The Physician directs the nurse to use oropharyngeal suctioning to remove liquid secretions for a client with respiratory problems. What is oropharyngeal suctioning?

removing secretions from the throat through an orally inserted catheter

A client is recovering from a recent stroke and the care team suspects that the client has been aspirating food, despite the use of a high texture diet. Aspiration of food and liquids into the lungs is associated with the nursing diagnosis? Select all that apply

risk of infection, ineffective Airway clearance, impaired gas exchange, ineffective breathing pattern

The client is sedated following cervical spine surgery. The nurse notes secretions are accumulating in the client's throat. An oral Airway is prescribed. Prior to inserting the airway the nurse

suctions the oropharyngeal area

A nurse is preparing to suction a client. Place the section procedure in the correct order

gather, adjust, provide, setup, insert, withdraw

An older adult client requires frequent suctioning because of copious secretions. The client is experiencing multiple health problems. During suctioning attempts, the nurse monitors the clients

heart rhythm

The Physician at the healthcare facility directs the nurse to perform vibration along with percussion on a frail client with a respiratory diagnosis. What is a possible outcome of Performing vibration on the client?

helps shake underlying tissue and loosen the retained secretions

a nurse is taking the health history of an older adult. Which factors in the client's history would raise the nurse is concerned about potential pathological changes in the client's pulmonary system? Select all the apply.

history of smoking cigarettes, occupation that involves inhaling pollutants, living in a heavily industrialized area

The client has thick secretions and an ineffective cough. The nurse selects the following fluid to administer to the client

iced tea

A client has had a tracheostomy and the nurse is prepared to conduct tracheotostomy care. What part of the tracheostomy tube is removed for cleaning?

inner cannula

A nurse is preparing to orally suction a client with dysphagia following a stroke. Which suction device is appropriate?

Yankauer catheter

The client is producing copious secretions and requires frequent suctioning. The client does not have a tracheostomy. To protect the nostril, the nurse

inserts a nasopharyngeal trumpet

Why is keeping clients with respiratory disorders well-hydrated an important nursing intervention?

it seems mucus, promoting its expectoration

A client with a 26 year history of smoking is recovering from pneumonia. Which information will be most important for the nurse to include in the discharge teaching?

options for smoking cessation

A nurse is completing tracheostomy suctioning on an older adult client. Which would be an indication to stop suctioning?

dysrhythmias

which physiological change does the nurse anticipate will be found in the older adult client with an ongoing non-productive cough?

laryngeal atrophy

A nurse is teaching a client and family about performing postural drainage. The nurse instructs the client to stop the procedure and resume a comfortable position if which of the following happens? Select all that apply

lightheadedness, rapid pulse rate, fatigue, or difficulty breathing

The nurse is caring for a client with ineffective Airway clearance. Which food will the nurse remove from the clients dietary tray?

milk

The nurse is to suction the narrow pharynx of a client. No equipment is in the room. There is a wall outlet for sectioning. Which equipment does the nurse gather? Select all that apply

suction kit, suction canister, connecting to bank, 500 mL container of sterile saline

The nurse is to suction a narrow pharynx of a client. No equipment is in the room. There is a wall outlet for suctioning. Which equipment does the nurse gather? Select all that apply

suction kit, suction canister, connecting tube, 50 ml container of sterile saline

What can a nurse ask a client to do before suctioning to prevent hypoxemia?

take several deep breaths

A nurse has an order to collect a sputum specimen I find admitted with acute bronchitis. When will be the best time to collect the specimen?

8 AM

The client measures the distance from the clients Front Teetto the angle of the jaw is slightly more than 3 in. The nurse is to insert an oral Airway and select one that measures

80mm

swallowing down the wrong pipe has happened to all of us. After a significant coughing spasm and gasping for air, we typically recover - none the worse for wear. Which upper Airway structure malfunctions to cause this event?

epiglottis

A client with a head injury will require long-term Airway support. Which device will be required for this client?

tracheostomy tube

The nurse is assessing a client with a history of asthma. Which assessment finding indicates that the nurse should take immediate action?

use of accessory muscles in breathing

Which statements accurately describe a step for inserting an oropharyngeal airway? Select all that apply

use, Airway, insert

a nurse is preparing to suction a client through a previously inserted oral Airway. What are the most important actions of the nurse before beginning the procedure? Select all that apply

wash hands, preoxygenate the client, open the suction kit

A nurse is taking the health history of an older adult. Which factor would raise the nurse is concerned about potential pathological changes in the client's pulmonary system?

working 20 years in a factory

The nurse is preparing to suction a client's Airway. How long will the nurse preoxygenate the client to achieve a maintenance spo2 of 95 - 100%?

1 - 2 minutes

a nurse is collecting a sputum specimen from a client. How much sputum should the nurse collect?

1 to 3 ml

The nurse is preparing to perform nasopharyngeal suctioning on an adult using a wall unit. What is the appropriate suction pressure setting for an adult?

100 to 120 mm hg

A nurse is preparing to perform oral suctioning of a 40 year old client. The nurse attaches the suction catheter and tubing to wall suction and sets the suction pressure at which level?

110 mm hg

a nurse is reviewing Home Care measures with a client who must perform postural drainage. The nurse advises the client to perform the exercise how often?

2 to 4/ day

The nurse is caring for four clients. Which client does the nurse identify that would best benefit from chest Physiotherapy?

21 year old client with cystic fibrosis

A nurse is teaching a client about postural drainage. What is the maximum duration, in minutes, that a client should hold each of the prescribed positions? Record your number using a whole number

45

A nurse is performing nasopharyngeal suctioning. When inserting the catheter, the nurse would most likely Advance the catheter to which distance?

5 - 6 in

The Physician directs the nurse to use section in to remove liquid secretions from a five-year-old client. If the nurse uses a portable suctioning machine, how much negative pressure would the nurse applied to drain the liquid secretion from a catheter

5 to 10 mm hg

An older adult client with a history of chronic obstructive pulmonary disease is admitted to the hospital with a cough and acute shortness of breath. Which priority action should the nurse take during the client assessment of the client?

Ask specific questions about the history of the cough and shortness of breath.

a nurse at the healthcare facility collect a sputum specimen of a client with pneumonia for a Laboratory test. Which action should the nurse perform after collecting the specimen?

Attach a label and laboratory request form to the specimen.

A nurse is teaching a client and her family about postural drainage. What should be included in the teaching plan? Select all that apply.

Complete postural drainage four times a day. Cough out any expectorated sputum and a tissue and dispose of it properly. Return to a comfortable position when tired, light headed, or short of breath.

when performing suctioning to remove the liquid secretions from a client with chest congestion, what should the nurse do to prevent hypoxia in the client?

Complete the process and no more than 15 seconds.

The client is prescribed postural drainage two times per day at home. When enforcing client instructions, the nurse States

Cough sputum into paper tissues.

A sputum specimen is to be collected from a client. What would the nurse do?

Encourage a forceful cough to expectorate sputum.

A client with chronic obstructive pulmonary disease (COPD) has an effective Airway clearance related to retained secretions as manifested by week and persistent cough. Which actions by the nurse would be most appropriate?

Encourage the client to sit up, lean slightly forward, and cough forcefully.

A client is being treated with intravenous antibiotics for pneumonia, a health problem that has been accompanied by production of copious, thick respiratory secretions. How can the nurse best reduce the viscosity (thickness) of the client's secretions?

Ensure that the client's fluid intake is sufficient at all times.

A nurse is preparing to insert an oral Airway. The nurse would position the client supine with the neck in which position?

Hyperextension

The nurse is preparing a client for a tracheostomy insertion with a fenestrated tracheostomy tube. Which statement made by the client indicates an accurate understanding of the fenestrated to?

I'm glad I was still be able to talk once I get this tube inserted.

A nurse has an order to obtain a sputum specimen on a newly admitted client. Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)

Label the sputum specimen and take it to the lab.

A nurse has just completed tracheal suctioning on a client. Which finding would the nurse interpret as indicating that the treatment was effective?

Lungs clear on auscultation.

A client returns to the unit following an insertion of a tracheostomy tube. Where should the nurse place the obturator?

Place the obturator and a plastic bag and put it at the bedside.

The nurse is to obtain a sputum specimen from the client. Which of the following actions would the nurse perform? Select all that apply.

Plan to collect a sputum in the morning, assist the client to a sitting position

A nurse is preparing to insert an oral Airway on an unconscious client. How should the nurse proceed?

Position the client with the neck hyperextended.

A nurse is caring for a client who is recovering from Dental anesthesia after cardiac surgery. The nurse uses an oral Airway for Airway management for this client. What is the purpose of an oral Airway?

Prevents obstruction of the upper Airway

A nurse is using inhalation therapy with a client. Which would not be administered through this method?

Protein therapy

a nurse is observing a new graduate suctioning a client's tracheostomy tube. Which intervention would cause the nurse to intervene?

Suction was applied when the catheter was inserted.

What is the rationale for placing a writing board in the room of a client who has had surgery to insert a tracheostomy tube?

The client is not able to speak.

A physician orders and oropharyngeal Airway to be inserted into a client. What accurately describes the use of the device?

The nurse can answer this device at the bedside with little to no trauma to the unconscious client.

a nurse is performing chest physiotherapy on an older adult client with chronic obstructive pulmonary disease who needs assistance mobilizing secretions. While performing vibration, when should the nurse use the palms of her hand to shake underlying tissue and loosen retained secretions.

When the client is exhaling

A client has just returned from getting a new tracheostomy inserted. When the nurse enters the room, the client is cyanotic, with a tracheostomy tube laying on the bed. What is the nurses priority action?

Ventilate the client with a resuscitation bag with mask.

The client has a chest incision under the left arm from cardiac surgery one week ago. The client now has pneumonia and has percussion during postural drainage prescribed. The nurse:

avoid striking the area under the left arm

nursing students are reviewing the structures of the airway. The students demonstrate understanding of the information when they identify what as responsible for moving collected debris upwards?

cilia

The client has a nursing diagnosis of ineffective Airway clearance related to retaining secretions as evidenced by moist lung sounds, respiratory rate of 28 to 30 breaths per minute, an ineffective cough. The nurse evaluates client outcome and determines the outcome is meant when the client demonstrates

clear lung sounds

The nurse is caring for an older adult client with pathologic pulmonary changes. The nurse should be aware that which conditions cause pathologic pulmonary change? Select all that apply

clients with a history of smoking, occupations where clients have inhaled pollutants, clients residing in area with toxic emissions

Which technique would the nurse employ to maximize the effectiveness of postural drainage?

combine it with percussion and vibration.

A nurse is caring for an unconscious client with an oral Airway. What should the nurse include in the care plan?

cough

A nurse on acute geriatric unit of the health care facility provides care for many clients who are being treated for pneumonia. What age-related change predisposes adults to pneumonia?

decreased ability of cilia to clear debris from lower airway

The nurse has a nursing diagnosis of ineffective Airway clearance related to retained secretions as evidenced by moist lungs sounds, respiratory rate of 28 to 30 breaths per minute, and an effective cough. Appropriate nursing interventions include which of the following? Select all that apply

monitor respiratory rate every hour and as needed. Ausculate lung sounds every 2 hours.

A client is ordered to receive nasal pharyngeal suctioning every 2 hours. Which of the following would the nurse anticipate using as a protective measure for the client?

nasopharyngeal trumpet

Students are reviewing information and mobilizing secretions. The students demonstrate a need for additional teaching when they identify what as a technique of chest Physiotherapy?

oxygen Administration

A nurse is performing tracheostomy care. The nurse cleans the inner cannula and then rinse is it in the Basin of normal saline. To complete the procedure, the nurse performs additional actions. Place them in the order in which the nurse would complete them, from first step to last.

tap, replace, clean, place

Which older adult clients are at increased risk for aspiration? Select all that apply

those who report I have trouble swallowing, those with late-stage dementia, those who are hospitalized following a stroke, those recovering from general anesthesia

A nurse is caring for a client who underwent a tracheostomy following throat surgery. What is the rationale for swapping the area around the outside of the trach tube with hydrogen peroxide?

to remove encrusted secretions