CNST Chapter 25: Airway Management
A patient using a nasal cannula has gurgling on inspiration. The nurse notes a productive cough but the inability to clear the secretions from the mouth. Which action should the nurse take first to prepare for oropharyngeal suctioning? a. Apply clean gloves and a mask. b. Insert the suction device to the back of the throat. c. Remove the patient's nasal cannula. d. Connect the tubing to a standard suction catheter.
A Perform hand hygiene and apply clean gloves. Apply a mask or face shield if splashing is likely. Insert the device into the mouth along the gum line to the pharynx. Remove the patient's oxygen mask, if present. A nasal cannula may remain in place. Connect one end of the connecting tubing to the suction machine and the other to a Yankauer suction catheter.
The nurse is caring for an infant who has been vomiting and is having difficulty breathing. What actions by the nurse are appropriate for suctioning the infant? a. Place the infant in a supine position. b. Suction only when a large amount of mucus is present. c. Suction for only 30 seconds. d. Compress the bulb syringe after it is placed in the nostril.
A Position infants with breathing problems or excessive vomitus in a supine or side-lying position. Airways of infants and children are smaller than those of an adult; even small amounts of mucus can cause airway obstruction. Suction should be completed for only 5 seconds with 30 to 60 seconds in between for the patient to reoxygenate. Compress the bulb syringe before insertion to prevent forcing secretions into the infant's bronchi.
The nurse is preparing to suction an infant with a tracheostomy tube. Which action by the nurse follows appropriate procedure? a. Using a suction catheter that is half the diameter of the tracheostomy tube b. Suctioning 0.2 to 0.5 inches beyond the tip of the tracheostomy tube c. Hyperoxygenating with 90% oxygen to avoid oxygen toxicity d. Using less than 150 mm Hg negative pressure
A Suction catheters for pediatrics should be half the diameter of the child's tracheostomy tube. The distance suctioned should be no greater than 0.5 cm (0.2 inches) beyond the tip of the artificial airway. To determine distance, the catheter is placed near a sample artificial airway. Hyperoxygenate with 100% oxygen in pediatric patients. Negative pressure for suctioning should not exceed 100 mm Hg.
The nurse is caring for a patient on mechanical ventilation with an endotracheal tube. Which nursing interventions will help prevent ventilator-associated pneumonia (VAP)? (Select all that apply.) a. Changing the patient's position every 2 hours b. Keeping the head of the bed elevated 30 to 45 degrees c. Providing oral care with a toothette every 8 hours d. Keeping the head flat during and for 30 minutes after enteral feedings
A, B Best-practice guidelines indicate that the following interventions are advantageous in preventing ventilator-associated pneumonia (VAP): elevating the head of the bed at 30 to 45 degrees to prevent aspiration, changing patient position every 2 hours to decrease risk for atelectasis and pulmonary infection, providing oral care with a toothbrush every 8 hours to remove dental plaque organisms (toothettes are not adequate to clean dental plaque, but they may be used between brushings for comfort), maintaining the endotracheal cuff pressures at 20 cm H2O to decrease movement of secretions to the lower airways, and carefully monitoring the patient for aspiration when enteral feedings are infusing.
The nurse is evaluating a patient to determine whether the endotracheal tube cuff is properly inflated. Which findings indicate proper inflation? (Select all that apply.) a. Exhaled tidal volume is 50 mL less than the tidal volume set on the ventilator. b. Air leak is heard with a stethoscope only at the end of inspiration. c. The patient is able to vocalize. d. Gastric contents are noted in airway secretions.
A, B The exhaled tidal volume from mechanical ventilation should not be less than 50 mL of the delivered tidal volume to ensure appropriate ventilation of the lungs. The air leak should be audible only with a stethoscope at the end of inspiration. Excessive phonation and gastric secretions in the airway indicate a partially deflated cuff.
A nurse is preparing to suction a patient via the nasotracheal route. Which conditions should the nurse recognize as contraindications to nasotracheal suctioning? (Select all that apply.) a. Motor vehicle accident with acute head injuries b. History of hemophilia c. Epiglottitis or croup d. Environmental allergies with sinus drainage
A, B, C Contraindications to nasotracheal suctioning include facial or neck trauma/surgery, acute head injuries, bleeding disorders, nasal bleeding, epiglottitis or croup, laryngospasm, irritable airway, and gastric surgery. These conditions are contraindications because the passage of a catheter through the nasal route causes additional trauma, increases nasal bleeding, or causes severe bleeding in the presence of bleeding disorders. In the presence of epiglottitis, croup, laryngospasm, or irritable airway, the entrance of a suction catheter via the nasal route causes intractable coughing, hypoxemia, and severe bronchospasm; this may necessitate emergency intubation or tracheostomy. Allergies with sinus drainage will increase the volume of secretions in the pharynx and may require suctioning.
The nurse performing nasotracheal suctioning should be assessing the patient for which possible unexpected outcomes? (Select all that apply.) a. Severe reduction in heart rate b. Wheezing and inability to breathe c. Reduction in oxygen saturation d. Nasal bleeding
A, B, C, D Nasotracheal suctioning has many risks associated with it. The most serious relate to hypoxemia, which often results in cardiac dysrhythmias, laryngeal spasm, and bradycardia (due to stimulation of the vagus nerve). Nasal trauma and bleeding can develop as the result of trauma from the suction catheter.
The nurse is caring for a patient who has a tracheostomy. To prevent the patient from developing an airway obstruction, the nurse assesses which of the following? (Select all that apply.) a. Patient's nutritional status b. Environmental humidity c. Existing respiratory infection d. Patient's ability to cough
A, B, C, D The patient's hydration and nutritional status, humidity delivered to the tracheostomy tube, the status of an existing infection, and the ability to cough are all factors that affect the amount and consistency of secretions in the tracheostomy tube and the patient's ability to clear the airway.
The nurse is providing care to a patient on mechanical ventilation with an endotracheal tube. The nurse carefully inflates the cuff of the endotracheal tube using the minimal leak method, knowing that a properly inflated cuff provides which benefits to the patient? (Select all that apply.) a. Prevents aspiration of gastric contents. b. Promotes accumulation of secretions below the epiglottis. c. Prevents air from escaping between the tube and the tracheal wall. d. Promotes lung inflation for mechanical ventilation.
A, C, D A cuff on an endotracheal tube prevents the escape of air between the tube and the walls of the trachea and reduces aspiration when a patient is receiving mechanical ventilation. The goals of correctly inflating the cuff on an artificial airway are to promote lung inflation for mechanical ventilation, prevent aspiration of gastric contents, and at the same time allow drainage of secretions that accumulate between the epiglottis and the cuff.
The nurse is assessing the risk for aspiration of gastric contents into the lungs resulting in airway obstruction. The nurse identifies patients with which conditions as having increased risk? (Select all that apply.) a. Presence of a gastrostomy feeding tube b. History of smoking 2 packs per day for 30 years c. Head injury with a decreased level of consciousness d. Stroke with dysphagia
A, C, D Conditions that increase the patient's risk for aspiration include enteral feeding tubes or other nasal or oral gastric tubes, a decreased level of consciousness, and a decreased swallowing ability.
The nurse is assessing a patient with an endotracheal tube and notes an audible air leak when standing by the patient. Which intervention should the nurse perform first to address this problem? a. Deflating the cuff of the endotracheal tube b. Repositioning the patient or tube c. Inserting a new endotracheal tube d. Notifying the health care provider
B If an air leak is audible with the ear, it is too large. Repositioning the patient or the tube may correct the problem. Reinflation of the cuff may be necessary. Prepare for insertion of a new tube by the health care provider or trained personnel if the cuff ruptures. Repositioning and reinflating the cuff are performed before the health care provider is notified.
The nurse is performing nasotracheal suctioning on a patient. The nurse should discontinue the suctioning if which of the following occurs? a. The patient coughs as the catheter is inserted. b. The heart rate decreases from 84 beats per minute to 60 beats per minute. c. An increase in pulse occurs from 74 beats per minute to 94 beats per minute. d. Oxygen saturation levels decrease from 97% to 94%.
B If the patient's pulse drops by more than 20 beats per minute, suctioning should be discontinued. The patient should cough, and this is expected. If the patient's pulse increases by more than 40 beats per minute or pulse oximetry falls below 90% or 5% from baseline, suctioning should be discontinued.
The nurse is assessing a patient who is intubated and on a ventilator. When listening above the sternal notch with a stethoscope, the nurse notes a minimal amount of air leak at the end of inspiration. Which action by the nurse is appropriate? a. Remove all air from the cuff and reinflate the cuff until no air leak is present. b. Note that the cuff is properly inflated. c. Notify the health care provider. d. Suction the patient.
B The cuff should be inflated to minimal leak. If the air leak is audible with the ear, it is too large. A properly inflated cuff should have a minimal air leak that is heard only with a stethoscope. The air should not be removed, the health care provider does not need to be notified, and the patient does not need to be suctioned because the cuff is properly inflated
A patient with increased secretions may develop airway obstruction. The nurse can promote a patent airway by using which of the following techniques? (Select all that apply.) a. Limiting fluid intake b. Positioning c. Deep breathing d. Humidity
B, C, D Hydration, positioning, deep breathing, and humidity are techniques that are helpful in maintaining a patent airway.
The nurse is providing care to a patient with a tracheostomy tube that has an inner cannula. Which intervention by the nurse follows proper procedure for tracheostomy tube care? a. Carefully removes the inner cannula and places it in a basin of 1:10 bleach solution b. Scrubs the inner cannula on the inside and outside with a 1:10 bleach solution c. After scrubbing the inner cannula, rinses it with normal saline d. Uses a wet 4 ´ 4 gauze and cleans the inside of the outer cannula
C After the inner cannula is thoroughly cleaned, it is rinsed with normal saline. The inner cannula is removed and is placed in a basin of normal saline to loosen secretions. It is scrubbed and then rinsed with normal saline. The outer cannula is not cleaned on the inside. The exposed outer cannula surfaces at the stoma are dried with a 4 ´ 4 gauze to prevent a moist environment and prohibit microorganism growth and skin excoriation
The nurse is suctioning a patient with an endotracheal tube. Which action should the nurse take when the patient develops respiratory distress? a. Quickly remove the catheter and carefully reinsert it. b. Continue to apply intermittent suction to remove thick secretions. c. Administer oxygen directly through the suction catheter. d. Withdraw the catheter and encourage the patient to cough and deep-breathe.
C If the patient develops respiratory distress during suctioning, the catheter should be immediately withdrawn and supplemental oxygen and breaths supplied as needed. In an emergency, disconnect suction and attach oxygen at the prescribed flow rate through the catheter.
The nurse is providing nasotracheal suctioning for a 13-year-old patient with secretions in the throat and trachea. Which action by the nurse demonstrates proper technique? a. Applying sterile petroleum jelly to the distal tip of the suction catheter b. Applying clean gloves to both hands c. Inserting the suction catheter 6 to 8 inches during inspiration d. Suctioning the pharynx first and then the trachea
C In older children, the suction catheter is inserted about 16 to 20 cm (6 to 8 inches). The catheter is always inserted during inspiration. The catheter should be lubricated with water-soluble lubricant to avoid lipid aspiration pneumonia from a petroleum-based gel. The procedure requires sterile gloves, at least on one hand. The trachea should be suctioned before the pharynx because the mouth and the pharynx contain more bacteria than the trachea
A patient with a tracheostomy tube is accidentally extubated. What should the nurse do immediately? a. Call the health care provider. b. Mechanically ventilate the patient. c. Insert a new tracheostomy tube. d. Hold the stoma open with the fingertips.
C Replace the old tracheostomy tube with a new tube. Some experienced nurses or respiratory therapists may be able to quickly reinsert the tracheostomy tube. A spare tracheostomy tube of the same size and kind should be kept at the bedside in the event of emergency replacement. Notify the health care provider after reestablishing the airway. Be prepared to manually ventilate the patient with an Ambu bag if respiratory distress develops until the tracheostomy is replaced. An endotracheal tube of the same size can be inserted in the stoma in an emergency.
A patient has been on mechanical ventilation with an endotracheal tube for 1 week. Which intervention by the nurse will help prevent ventilator-associated pneumonia (VAP)? a. Providing oral care with a toothbrush at least twice daily b. Changing the ventilator circuits at least every 72 hours c. Removing subglottal secretions before every position change d. Maintaining endotracheal cuff pressures at 10 cm H2O
C Subglottal secretions should be removed every 4 to 6 hours or before position changes. Oral care should be provided with a chlorhexidine swab or toothbrush (if chlorhexidine is contraindicated) every 8 hours. The ventilator circuits should be changed every 48 hours because of potential bacteria within the tubing condensation. The endotracheal cuff pressures should be maintained at 20 cm H2O to decrease movement of secretions into the lower airways.
The nurse is performing nasotracheal suctioning for a patient. Which action by the nurse is appropriate? a. Applying intermittent suctioning while slowly withdrawing the suction catheter b. Carefully pushing the suction catheter in and out while applying suction c. Applying suction for 15 seconds or less d. Asking the patient to deep-breathe for 15 seconds before passing the catheter a second time
C Suction should be applied for 15 seconds or less to avoid cardiopulmonary compromise from hypoxemia or vagal overload. Continuous suction and back and forth rotation of the catheter are now recommended because studies show that tracheal damage from intermittent and continuous suctioning was similar. The catheter should be rotated back and forth, not pushed in and out. At least 1 minute should be allowed between suction passes for ventilation and oxygenation.
A patient on mechanical ventilation with an endotracheal tube requires suctioning. A closed in-line catheter is in place. Which action by the nurse is appropriate? a. Use manual ventilation to hyperoxygenate the patient with 100% oxygen via Ambu bag. b. Push the catheter and slide the plastic sleeve back when the patient exhales. c. Push the catheter in until resistance is felt or the patient coughs. d. Apply suction for no longer than 30 seconds as you remove the catheter.
C The catheter is pushed in while the plastic sleeve is slid back between the thumb and forefinger until resistance is felt or the patient coughs. Hyperoxygenation is done by adjusting the FiO2 setting on the ventilator. Manual ventilation is not recommended. The catheter is pushed in when the patient inhales. Suction is applied for no longer than 15 seconds.
The student nurse is preparing to perform nasotracheal suctioning on an adult patient wearing a face mask. Which action by the student should the nursing instructor question? a. Increasing the oxygen flow rate for the face mask and asking the patient to deep-breathe slowly before suctioning b. Inserting the catheter into the nares slanting slightly downward c. Asking the patient to swallow while the catheter is being inserted d. Inserting the catheter about 8 inches without applying suction
C The suction catheter should not be inserted during swallowing because it will most likely enter the esophagus. Insert during inhalation because the epiglottis is open. The patient should be hyperoxygenated before suctioning. The oxygen flow rate can be increased on the face mask, and the patient can deep-breathe slowly to accomplish this. The catheter should be inserted along the natural course of the nares—slightly slanted downward. In adults, the catheter is inserted about 20 cm (8 inches).
The nurse is assessing several patients who have returned from surgery. Which finding most likely indicates a need for suctioning? a. Complaint of pain when breathing b. Cough producing thick yellow mucus c. Oxygen saturation level of 88% d. Drowsiness and respiratory rate of 8
C When a patient's oxygen saturation falls below 90%, this is a good indicator of the need for suctioning. Pain with breathing is probably related to the surgery. If a cough is productive, suctioning is not necessary. Drowsiness and a decreased respiratory rate may be due to administration of pain medications such as opioids.
The nurse is assessing a patient with an endotracheal tube on mechanical ventilation. Which assessment finding indicates a partially deflated cuff? a. Increased exhaled tidal volume b. Spasmodic coughing c. Tense test balloon on the endotracheal tube d. Vocalizations by the patient
D A partially deflated cuff allows secretions to enter the trachea and permits vocalization. Other signs of an underinflated cuff are decreased exhaled tidal volume, a flaccid test balloon on the tube, and gurgling on expiration. An overinflated cuff can cause spasmodic coughing and a tense test balloon on the tube
When assessing a patient's tracheostomy site, the nurse notes redness and inflammation around the stoma. Which intervention can the nurse provide to address this problem? a. Decrease the frequency of tracheostomy care. b. Apply a dry gauze dressing just under the stoma. c. Remove the ties at frequent intervals. d. Apply a topical antibacterial solution and allow it to dry.
D Apply a topical antibacterial solution and allow it to dry. Increase the frequency of tracheostomy care. Apply a hydrocolloid or transparent dressing just under the stoma to protect the skin from breakdown. Consult with a skin-care specialist. Adjust the ties or apply new ones when the ties are loose or tight. Never remove the ties.
The student nurse is providing tracheostomy care to a patient who has intratracheal secretions and a damp tracheostomy dressing and ties. Which action by the student should the nursing instructor question? a. Suctioning the tracheostomy tube before removing the soiled tracheostomy dressing b. Assisting the patient to semi-Fowler's position c. Placing new tracheostomy ties before cutting the old ties d. Cutting gauze pads to place around the tracheostomy tube
D Do not use scissors to cut gauze pads as they may shed fibers that could be inhaled by the patient. Use a manufactured pad with a slit. Suctioning the tube removes secretions to avoid occluding the outer cannula while the inner cannula is removed. Usually a supine or semi-Fowler's position is used to promote patient comfort and prevent muscle strain for the nurse. If changing ties without an assistant, the old ties are not cut until the new ties are securely in place.
A patient with a tracheostomy tube has thick, tenacious mucus that is difficult to remove. The nurse should choose which technique to suction the airway? a. Normal saline instillation (NSI) before suctioning b. Dry suctioning 1 time followed by NSI with suctioning 2 more times c. Dry suctioning as long as the heart rate is above 60 beats/min d. Dry suctioning
D Normal saline instillation (NSI) into artificial airways is no longer recommended as standard practice. Clinical studies show that suctioning with or without NSI produces similar amounts of secretions and significant decreases in oxygen saturation. Potential side effects include increases in heart rate for 4 to 5 minutes after suctioning using NSI as opposed to dry suctioning. NSI has the potential to increase ventilator-associated pneumonia because bacteria from the upper airway can be dislodged to the lower airway.
After oropharyngeal suctioning of a patient, the nurse notes bloody secretions in the suction catheter and tubing. What should the nurse do next? a. Increase the suction pressure. b. Provide additional oxygen. c. Reduce the frequency of oral hygiene. d. Check the suction catheter for nicks.
D Observe the catheter tip for nicks, which can cause mucosal trauma. The nurse should assess the oral cavity for trauma or lesions, reduce the amount of suction pressure used, provide supplemental oxygen only if respiratory distress occurs, and increase the frequency of oral hygiene.
A patient with head trauma following a motor vehicle accident is on mechanical ventilation with an endotracheal tube. Which action by the nurse will reduce the risk for elevations in intracranial pressure during suctioning? a. Avoid hyperoxygenating the patient before suctioning. b. Insert the suction catheter just to the end of the endotracheal tube. c. Apply suction while inserting the catheter. d. Limit suctioning to 2 times with each suctioning procedure.
D Suctioning can cause elevations in intracranial pressure in patients with head injury. To reduce the risk, the nurse should hyperoxygenate the patient before suctioning and should suction only twice with each suctioning procedure. The catheter is inserted past the end of the endotracheal tube until resistance is met to adequately remove secretions from the airway. Suction should be applied while the catheter is removed.
The nurse is caring for a patient with an oral endotracheal tube in place. Which intervention by the nurse demonstrates proper procedure when providing endotracheal tube care? a. Determining proper endotracheal tube depth by noting the length of tube beyond the gum line b. Instructing the assistant to hold the tube away from the lips while changing the tape c. Removing the oral airway if the patient is actively biting down after the tape is removed from the endotracheal tube d. Repositioning the tube on the opposite side or at the center of the mouth at least every 24 to 48 hours
D The endotracheal tube should be repositioned to the opposite side or at the center of the mouth every 24 to 48 hours to prevent formation of pressure sores at the sides of the mouth. The proper depth of the endotracheal tube is determined by noting the centimeter mark at the lip or gum line. This line is marked on the tube and is recorded in the patient's record at the time of intubation. The tube should not be held away from the lips because this allows too much "play" in the tube and increases the risk for tube movement and accidental extubation. The oral airway should not be removed if the patient is actively biting down until tape partially or completely secures the tube.
The nurse has completed suctioning a patient's airway. Which action should the nurse take first? a. Reduce the suction level to medium. b. Remove the face shield and save for future suctioning. c. Reposition the patient and assist with oral hygiene using sterile gloves. d. Pull the gloves off over the rolled catheter and discard.
D When suctioning is completed, disconnect the catheter from the connecting tubing. Roll the catheter around the fingers of the dominant hand. Pull the glove off inside out so that the catheter remains coiled in the glove. Pull off the other glove over the first glove in the same way. Discard in an appropriate receptacle. The suction device should be turned off when suctioning is complete. There is no further need for suction. Remove the face shield and discard into an appropriate receptacle. Apply clean gloves to give personal care.
A patient has extremely copious and thick oral secretions. The nurse provides oropharyngeal suctioning using a _________________ suction device.
Yankauer or tonsillar tip Yankauer tonsillar tip A Yankauer, or tonsillar tip, suction device is used for oropharyngeal suctioning. This catheter is used instead of a standard suction catheter when oral secretions are extremely copious and thick, because it can handle large volumes of secretions better than a standard suction catheter can. The Yankauer suction catheter is angled to facilitate removal of secretions through a patient's mouth.
A plastic or rubber tube that is inserted through the nares or mouth past the epiglottis and vocal cords to maintain an airway is known as an _________________.
endotracheal (ET) tube endotracheal tube An ET tube is inserted through the nares (nasal ET tube) or the mouth (oral ET tube) past the epiglottis and vocal cords, into the trachea. ET tubes usually are made of plastic or rubber.
Too much oxygen reduces the drive to breathe in patients with chronic _____________.
hypercapnia Too much oxygen reduces the drive to breathe in patients with chronic hypercapnia (elevated arterial carbon dioxide tension).
A _______________ is inserted directly into the trachea through a small incision made in the patient's neck.
tracheostomy (trach) tube tracheostomy tube trach tube A tracheostomy tube is inserted directly into the trachea through a small incision made in the patient's neck.
