Funds Chapter 41 Oxygenation

The nurse pays a home visit to a patient on a home oxygen-delivery system. The nurse finds that the patient is lying on the bed and is not breathing, and there is no pulse. What is the nurse's immediate next step?

Absence of pulse and respiration indicates cardiac arrest. In this situation, the nurse should immediately call 911 and request an ambulance. If the nurse does not call 911, no advanced life support will come to the aid of the patient. The next step is to perform cardiopulmonary resuscitation. This includes doing chest compression, and establishing airway and breathing. Checking the home oxygen-delivery system is not a priority when the patient has a cardiac arrest. Doing so can cause a delay in performing resuscitation. Once the patient is resuscitated, the nurse can focus on establishing airway, breathing, and circulation. pp. 903, 904

What complications are associated with invasive mechanical ventilation?

Volutrauma, gastrointestinal disturbances, and ventilator-assisted pneumonia are complications associated with invasive mechanical ventilation. Skin breakdown and nasal injury are the complications associated with noninvasive mechanical ventilation. pg. 897

What does a Venturi mask do for a patient?

A Venturi mask is a high-flow delivery device that provides a specific amount of oxygen with added humidity. Partial and nonrebreather masks do not dry mucous membranes. Simple face masks are useful for short periods, such as patient transportation. pg. 903

Upon auscultating the lungs of a patient who has abnormal airway clearance, the nurse hears abnormal lungs sounds from both lungs. The patient also reports difficulty breathing and a cough with thick and yellow sputum. Which intervention would most benefit the patient?

A patient who has abnormal lung sounds in lobes, dyspnea, and a cough with thick and yellow sputum may have ineffective airway clearance. Providing the patient with nasotracheal suction may help to prevent thick and tenacious secretions from obstructing the airway. A patient who has impaired gas exchange related to pulmonary secretions may benefit from being positioned in a high-Fowler's position, but the benefits would not be as immediate as in nasotracheal suctioning. A patient at risk for imbalanced body temperature may benefit by receiving intravenous antibiotics. A patient who has fatigue related to decreased oxygenation may benefit from progressive ambulation. pg. 895

The nurse is assessing the history of allergies in a patient. Which questions should the nurse include in the questionnaire?

Allergies are manifested in various ways. They may involve minor symptoms such as running nose or rash or a life-threatening condition such as anaphylaxis. In order to assess patient history for allergies, it is extremely important for the nurse to know the allergen. It is also important to know the relief measures and medications that the patient takes for allergies. Allergy symptoms vary from person to person. Hence, it is important to understand what symptoms this patient suffers. The management would vary according to the symptoms. An allergy attack persists until the patient is not in contact with the allergen or takes medication. Hence the question of time limit is not very important. A patient may have multiple allergy attacks; hence the question about number of reactions is not of prime importance. p. 883

What is the most serious complication of a tracheostomy?

An airway obstruction is the most serious complication of a tracheostomy. Hypoxemia, arrhythmia, and hypotension are caused by too frequent suctioning. pg. 911

A patient reports having shortness of breath and fatigue on brisk walking for the past 2 weeks. The patient has also experienced menorrhagia for the past 2 months. The patient's blood reports show decreased hemoglobin and an increased red blood cell count. Which condition is the patient most likely experiencing?

An examination would likely indicate that the patient has anemia as a result of menorrhagia. In anemia, oxygenation decreases. Over a long period, the body responds by increasing the production of red blood cells, resulting in polycythemia. Surfactant is a chemical produced by the lungs that prevents alveolar collapse. It is highly unlikely the patient has decreased surfactant. Lung compliance is the ability of the lungs to expand and is affected by intraalveolar pressure. A decrease in the fraction of inspired oxygen concentration occurs in upper or lower airway obstruction. pg. 876

Which nursing intervention is appropriate for preventing atelectasis in the postoperative patient?

An incentive spirometer is used to encourage deep breathing to inflate alveoli and open pores of Kohn. Postural drainage, chest percussion, and suctioning are used to treat atelectasis and increased mucus production. An incentive spirometer is used to encourage deep breathing to inflate alveoli and open pores of Kohn. Postural drainage, chest percussion, and suctioning are used to treat atelectasis and increased mucus production. pg. 896

The registered nurse asks the patient and family to state safety guidelines, emergency precautions, and an emergency plan for the patient who is using home oxygen equipment. What is the rationale behind this?

Asking the patient and family members to state safety guidelines, emergency precautions, and emergency plans for use of home oxygen equipment helps determine the patient's knowledge of what to do if power fails, equipment fails, or the patient's status worsens. Using the teach-back technique to determine the patient's and family's ability to use home oxygen equipment helps to evaluate what the patient and family can implement themselves. Monitoring oxygen delivery rate helps to determine if the patient is using oxygen at a prescribed rate. Asking the patient and family members about ease of administering, or any problems with the home oxygen delivery system helps to determine their ability to deal with stressors associated with home oxygen use. p. 929

A patient's laboratory report shows the presence of blood-tinged sputum. Which diagnostic tests are beneficial for the patient in this situation?

Blood tinged sputum indicates the presence of hemoptysis, which is associated with coughing and bleeding from the upper respiratory tract and sinus drainage. A bronchoscopy, sputum specimen, and chest x-ray examination are used to diagnose the cause of hemoptysis. A lung scan is used to examine normal lung structure without masses. Pulmonary function tests are used for basic ventilation studies. pg. 882

A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though the patient's color is ruddy, not cyanotic, the nurse understands that the patient is at risk for decreased oxygen-carrying capacity of blood because of which effect of carbon monoxide?

Carbon monoxide (CO) strongly binds to hemoglobin, making it unavailable for oxygen binding and transport. Salicylate poisoning, amphetamine use, and diabetic ketoacidosis can stimulate hyperventilation causing respiratory alkalosis. Arterial blood gas (ABG) levels are not routinely used to diagnosis CO poisoning, but these patients are usually found to have metabolic acidosis if they are tested. CO poisoning does not cause the alveoli to overinflate. pg. 896

Which abnormality change in the fingertips iscaused by chronic hypoxemia?

Clubbing in the fingertips is associated with chronic hypoxemia. Edema is associated with kidney disease. Distention is caused by right-sided heart failure. Splinter hemorrhages are caused by bacterial endocarditis. p. 884

Which statements are true regarding endotracheal and tracheal airways?

Endotracheal tube insertion is a complex technique that requires specialized skills. Therefore, a specially trained clinician should insert the endotracheal tube to ensure the patient's safety. Tracheostomy suctioning should be performed to clear the secretions only when necessary because suctioning too frequently may lead to hypoxemia, hypotension, and arrhythmias. Tracheostomy tube insertion may cause complications such as partial or complete airway obstruction due to a buildup of respiratory secretions. An endotracheal tube is a short-term artificial airway; it is not used for long-term assistance. An endotracheal tube is passed directly through the patient's mouth, past the pharynx, and into the trachea; it is not inserted by making a surgical insertion in the trachea. p. 896

A patient complains of chest pain and discomfort. Which diagnostic studies should the nurse anticipate?

Excessive cholesterol can lead to atherosclerosis, which further leads to myocardial infarction or angina. Determination of cholesterol level is essential. An electrocardiogram helps in assessing the electrical activity of the heart and helps in diagnosing disturbances in cardiac activity. Cardiac enzymes are essential in determining any ischemic heart disorder or myocardial injury. Electroencephalogram is used to determine activity of the brain. Ultrasonography of the pelvis helps in assessing disorders of organs in the pelvic region. pp. 884-885

After examining a patient's eyes, the primary health care provider confirms cyanotic conjunctivae. What might be the cause of the abnormality?

Hypoxemia may cause cyanotic conjunctivae. Hypoxia may be due to cyanosis. Hyperlipidemia may cause xanthelasma. Bacterial endocarditis may cause petechiae on conjunctivae. p. 884

What is hypoxia?

Hypoxia is inadequate tissue oxygenation at the cellular level. Hypoxia occurs due to a deficiency in oxygen delivery or oxygen use at the cellular level. Decreased circulating blood volume results in hypoxia to body tissues. Hypovolemia is caused by extracellular fluid loss and reduced circulating blood volume. Hyperventilation is a ventilation state in which the lungs remove carbon dioxide faster than it is produced by cellular metabolism. pg. 877

The nurse is providing care for a patient with tracheostomy. Which nursing interventions help to reduce redness and swelling around the stoma site?

It is the responsibility of the nurse to ensure the patient's comfort. The nurse should check the tube to prevent complications such as infections. The nurse can reduce redness and swelling around tracheostomy tube by placing a dressing. Redness and swelling due to secretions can also be reduced by applying an antiseptic solution. Application of a bag-valve mask does not reduce the incidence of redness and swelling. The tracheostomy tube can be replaced with a new one with adherence to strict aseptic technique. p. 922

Which nursing intervention prevents impaired oxygenation in a patient with a tracheostomy?

Maintaining the patency of the airway prevents impaired oxygenation in a patient with a tracheostomy. Auscultating lung sounds and observing the respiratory rate and depth provides a baseline measure of ventilation and ease of breathing. Assisting the patient to a supine position facilitates completion of the procedure without causing the patient discomfort. p. 915

Which type of suctioning should be performed before pharyngeal suctioning?

Nasotracheal suctioning is performed before pharyngeal suctioning whenever possible because the mouth and pharynx contain more bacteria than the trachea. Orotracheal suctioning is necessary when a patient who has pulmonary secretions is unable to manage secretions by coughing and does not have an artificial airway. Oropharyngeal and nasopharyngeal suctioning is used when a patient is unable to clear secretions. pp. 909, 910

Which complications occur in a patient with noninvasive ventilation?

Noninvasive ventilation causes complications that include facial injury, skin breakdown, and dry mucous membranes. Sinusitis and ventilator-associated pneumonia are avoided with noninvasive ventilation. p. 897

What could be the purpose of noninvasive ventilation?

Noninvasive ventilation is used to treat atelectasis by inflating the alveoli and reducing pulmonary edema by forcing fluid out of the lungs back into the circulation. It also improves alveolar ventilation and maintains positive airway pressure. Invasive mechanical ventilation reduces intracranial pressure and decreases oxygen consumption. p. 897

A nurse prepares to perform tracheal suctioning through an endotracheal tube. What is the rationale behind the nurse refraining from instilling normal saline in conjunction with endotracheal suction?

Normal saline instillation in conjunction with endotracheal suction results in the spread of microorganisms into the lower respiratory tract. Also, the oxygenation saturation is decreased. A patient who has chronic obstructive pulmonary disorder (COPD) and who is breathing spontaneously should never receive high levels of oxygen therapy because it results in a decreased stimulus to breathe. Hypocarbia results from hypoventilation prior to suctioning a patient who has a head injury. The nurse should be cautious while suctioning patients who have head injuries because of the risk of increased intracranial pressure (ICP). The risk is reduced by hyperventilating prior to suctioning, which results in hypocarbia. This, in turn, induces vasoconstriction, which reduces the potential increase in ICP. p. 911

The registered nurse suspects a buildup of secretions in the airways. These secretions were suspected to impair the patient's oxygenation while performing artificial airway care. Which assessment made by the nurse is least likely to support the suspicion of an accumulation of secretions?

Observing the condition of the surrounding tissues determines whether the patient is at risk for potentially impaired skin integrity and infection. This assessment may not support the suspicion of secretions impairing artificial airway care. Auscultating lung sounds and observing the patency of the airways and respiratory rate and depth helps to assess for the presence of secretions by the diminished breath sounds, which are signs of airway obstruction. Their effect on impairing the patient's oxygenation while performing artificial airway care can be determined by these assessments. pg. 915

A patient is undergoing suctioning and experiences a cough, but is unable to manage secretions. Which type of suctioning should occur in this situation?

Orotracheal and nasotracheal suctioning is necessary when a patient with pulmonary secretions is unable to manage secretions by coughing and does not have an artificial airway. Nasotracheal suctioning is used to clear the mouth and trachea. Pharyngeal suctioning is used to clear the pharynx for the purposes of getting rid of bacteria. Oropharyngeal and nasopharyngeal suctioning is used when the patient can cough and is unable to clear the secretions. pg. 895

A patient reports having shortness of breath for 2 months. The nurse asks the patient to rate the shortness of breath on a scale of 0 to 10 and state whether it is affecting daily activities. The nurse also asks about exposure to passive smoking and whether the patient feels comfortable when sleeping in a reclining chair. Which question asked by the nurse is about orthopnea?

Orthopnea occurs when the patient feels short of breath while sleeping, but comfortable when sleeping in a reclining chair. In a reclined position, the patient may also use multiple pillows to facilitate breathing. Orthopnea is quantified based on the number of pillows used. The question about exposure to passive smoking gives information about the predisposing factors to the complaints. The question about symptoms affecting daily activities indicates the severity of the symptoms. The question to rate dyspnea gives information about severity of the complaints.

Which age-related changes in the older adult may result in decreased tissue oxygenation due to impaired chest expansion?

Ossification of costal cartilage, decreased intervertebral space, and diminished respiratory strength will all impair chest expansion, which leads to decreased tissue oxygenation. A change in the cough mechanism may lead to atelectasis, due to retained pulmonary secretions. An impaired immune system can cause respiratory infections but won't impair chest expansion. p. 879

Why would the nurse request a humidification device while delivering oxygen to a patient in the home care setting?

Oxygen delivery greater than 4 L/minute may cause drying of the mucosal membrane; therefore, a humidification device may be required while delivering oxygen. Storing oxygen delivery devices upright helps ensure safe use of equipment. If symptoms of hypoxia are noticed in the patient, the oxygen demand may be increased and the primary health care provider should be notified. Placing equipment at least 8 ft from a heat source prevents injury from a possible fire. p. 927

What are the disadvantages of using an oxygen-conserving cannula?

Oxygen-conserving cannula cannot be cleaned and are more expensive. Simple face masks may increase the risk of aspiration and induce feelings of claustrophobia. Simple face masks are contraindicated in patients who retain carbon dioxide. p. 903

Which is the most common complication in a patient with a tracheostomy?

Partial airway obstruction is the most common complication in a patient with a tracheostomy. Pneumonia and pneumothorax also occur in patients with a tracheostomy but are not common. Nasal injury is associated with noninvasive ventilation. p. 896

The nurse is teaching a patient about coughing and deep breathing techniques. Which points should the nurse include in this teaching?

Patients should be advised to take a deep breath and then cough deeply. This allows mucus to be expectorated. Patients with upper and lower respiratory tract infections should be asked to deep breathe and cough every 2 hours while awake. While practicing a cascade cough, the patient should take a deep breath and hold for 2 seconds followed by a series of coughs. This ensures that the tissues are oxygenated well before the cough is induced. Coughing should never be suppressed. The mucus should be expectorated as much as possible. Breaths should be deep and good; shallow breathing is not advised. p. 892

Which nursing intervention maintains the patient's supply of oxygen?

Placing a tracheostomy tube over the outer cannula will help to maintain the patient's supply of oxygen. Hyperventilating the patient and securing the "locking" mechanism helps to secure the inner cannula and reestablish the oxygen supply. Rinsing the inner cannula with normal saline solution will remove secretions from the inner cannula. pg. 919

After inserting a chest tube, the nurse places the drainage system below the level of tube insertion. What is the rationale behind the intervention?

Placing the drainage system upright and below the level of tube insertion facilitates the drainage and maintains proper functioning of the system. Adjusting the tubing to hang in a straight line from the top of the mattress to drain the chamber prevents fluid or blood from accumulating in the pleural cavity. Ensuring that the tube connection between the chest and a drainage tube is intact and taped reduces the risk of an air leak causing breaks in the airtight system. Coiling the excess drainage tubing on the mattress next to the patient prevents excess tubing from hanging over the edge of mattress that may occlude the drainage system. p. 923

After endotracheal intubation, the patient coughs continuously. What may be the reason for this condition?

Placing the endotracheal tube at the level of the carina may result in cough reflex. Overinflating the cuff may lead to ischemia and necrosis of the tracheal tissue. The tube may become dislodged due to inadequate tube size. An endotracheal tube placed for a long time may increase the risk of infection. p. 915

Which unexpected outcomes are minimized by providing frequent oral care to a patient who has chest tubes?

Providing frequent oral care to a patient who has chest tubes may help minimize epistaxis and dry nasal and upper airway mucosa. Hypoxia can be minimized by checking that the oxygen-delivery device is patent, the tube is not kinked, and that an oxygen flow meter is attached. Skin irritation or skin breakdown can be minimized by adjusting the tightness of the elastic strap to a loose fit. pp. 922-926

While performing endotracheal tube care, which actions by the nurse reduce anxiety, encourage cooperation, and reduce risks associated with the treatment?

Providing reassurance by comforting the patient by explaining the procedure helps to reduce the patient's anxiety and encourages cooperation, thereby reducing the risks associated with the treatment. Coughing may cause complications in a patient who is receiving endotracheal tube care. Explaining to the patient the risks associated with coughing helps to reduce the risks associated with it. Placing the patient in the supine position provides access to the site and facilitates completion of the procedure without causing the nurse or patient discomfort. Obtaining assistance from available staff reduces the risk for accidental extubation. Placing a towel across the patient's chest helps to reduce the transmission of microorganisms to linens and bedclothes. pp. 915, 916

Which diagnostic test provides instant feedback about a patient's oxygenation status?

Pulse oximetry is a diagnostic test provides instant feedback about a patient's oxygenation level. Capnography is a diagnostic test that provides instant information about the patient's ventilation and perfusion. Bronchoscopy allows for visual examination of the tracheobronchial tree. Thoracentesis is a surgical procedure done on the chest wall and pleural space to take a biopsy specimen. p. 880

A child who has a spinal cord injury has difficulty breathing. After suctioning, the child is found to have tracheal edema. Which rationale would best explain this?

Shallow suctioning is preferred in children because deep tracheal suctioning may lead to tracheal edema. Suctioning frequently may lead to hypoxemia, hypotension, arrhythmias, and possible trauma to the mucosa of the lungs. Hyperventilating before suctioning a patient with a head injury reduces the risk of increased intracranial pressure. The suction time should not exceed 10 seconds because of the risk for suction-induced hypoxemia. p. 910

Which type of oxygen mask is contraindicated for patients who have carbon dioxide retention?

Simple face masks are contraindicated in patients who have carbon dioxide retention because retention can be worsened. Venturi masks, nasal cannulas, and partial rebreathers will not cause further worsening of the retention, so they are not contraindicated.

Which finding is the nurse least likely to observe in a client receiving invasive mechanical ventilation?

Sinusitis is a complication associated with noninvasive ventilation (such as CPAP) versus invasive ventilation. A pressure area around the tube is possible. The nurse must perform care of the airway tube routinely to prevent a pressure area from forming. Airway obstruction and pneumonia are potential complications of invasive mechanical ventilation. p. 922

What is the rationale for leaving space to snugly fit two fingers under the neck strap while placing tracheostomy tube?

Skin necrosis can be prevented by leaving a small gap under the neck strap. Infection can be controlled by regular cleaning of the cannula. Preoxygenation can prevent oxygen loss during suctioning. Displacement of the tracheostomy tube can be prevented by maintaining a secure hold on the tracheotomy tube. p. 921

The nurse is counseling a patient's caregiver regarding tracheostomy care at home. Which statement if made by the caregiver indicates the need for further teaching?

The caregiver should not remove the outer cannula unless instructed to by the primary health care provider. The tracheostomy tube should be covered to protect it from dust or cold air. Tracheostomy care should be performed at least once a day to ensure the function of the tube and prevent infection. The caregiver should notify the primary health care provider if the patient experiences pain longer than 1 week after insertion of the tube. p. 922

While assessing a patient who has a chest tube, the nurse suspects tension pneumothorax. Which symptoms in the patient support the nurse's suspicion?

Tension pneumothorax is the progressive build-up of air within the pleural space. It is characterized by tachycardia, hypotension, and stabbing chest pain. Cyanosis and decreased breath sounds are symptoms of increased respiratory distress. p. 925

The registered nurse is teaching a licensed practical nurse about the insertion of artificial oral airways. Which statement by the licensed practical nurse indicates the need for further teaching?

The airway should be inserted by initially pointing the curved end upward, and once it reaches the back of the mouth, it should be turned downward to follow the natural curve of the tongue. The airway should be inserted by placing it over the tongue. Inserting the airway in such a way that the flange rests against the patient's teeth is a correct insertion technique that helps to prevent airway obstruction. When the airway is in the oropharynx, turn the airway in such a way that the opening points downward to prevent airway obstruction. p. 895

When is it appropriate to use this catheter shown in the image below? (picture of a closed suction catheter)

The figure represents a closed suction catheter. It is most often used on patients who require invasive mechanical ventilation to support their respiratory efforts. This catheter decreases the risk of oxygen desaturation. It is used as a reusable sterile suction catheter that is encased in a plastic sheath to protect it between suction sessions. It permits the continuous delivery of oxygen while suction is performed.

What is the function of this instrument? (Artificial Oral Airway)

The image depicts an oral artificial airway. It prevents obstruction of the trachea by displacement of the tongue into the oropharynx. A suction catheter helps to clear respiratory secretions. Endotracheal tubes facilitate mechanical ventilation. Incentive spirometry is used to achieve optimal inhalation. p. 895

...

The image signifies that the nurse is attaching a catheter to a suctioning device. A Yankauer catheter is inserted into the patient's mouth. The tip of the catheter is placed into sterile basin followed by suctioning a small amount of normal saline by occluding the suction vent. The application of suction pressure while introducing a catheter into nasopharyngeal tissues increases the risk of damage to mucosa. p. 914

Which initial dressing applications are required for endotracheal tube care?

The initial dressing application of endotracheal tube care requires tincture of benzoin, liquid adhesive, and 0.12% to 0.20% chlorhexidine mouthwash. Scissors, twill tape, and a small sterile brush are required for tracheostomy care. p. 915

The oxygen saturation level of a patient is 90 percent after suctioning. What is the possible reason for this?

The normal oxygen saturation level is 95 percent or greater. An oxygen saturation level of 92 percent or less indicates hypoxemia. Performing endotracheal suctioning with normal saline instillation causes the spread of microorganisms into the lower respiratory tract, which reduces the oxygen saturation level. Oxygen should not be delivered at a rate higher than 2 L/min without the health care provider's acceptance. Performing hyperventilation prior to suctioning will reduce the risk of elevation in the intracranial pressure in a patient who has a head injury. Tracheal suctioning should be performed before pharyngeal suctioning because the pharynx contains more bacteria than the trachea, but it is not associated with a decreased oxygen saturation level. p. 906

The nurse is caring for a patient who has a chest drainage system. Which assessment findings may indicate that the patient is at risk for developing a tension pneumothorax?

The normal range of heart rates is 60 to 100 bpm. The increase in the heart rate indicates tachycardia. A normal blood pressure is 120/80 mm Hg. A decrease in the blood pressure may indicate hypotension. Rating the pain in the chest as 4 on a scale of 1 to 10 indicates severe pain. Tachycardia, hypotension, and pain in the chest indicate tension pneumothorax. SpO 2 of 95% is a normal finding. A respiratory rate of 18 bpm is also a normal finding. pg. 923-924

The nurse is caring for a patient with an endotracheal tube. Which of the nurse's actions requires correction?

The nurse should clean the oral airway with warm, soapy water, not plain water, to promote hygiene and reduce the transmission of microorganisms. The nurse should hold the endotracheal tube firmly at the patient's lips to maintain proper tube positioning and to prevent accidental extubation. The nurse should keep the endotracheal tube cuff inflated to reduce the risk for aspiration and accidental extubation. The nurse should clean the patient's face and neck with a soapy washcloth to prevent adhesive tape adherence. p. 918

While performing endotracheal tube care, the nurse insists that the nursing assistive person not hold the patient's endotracheal tube away from the lips or nares. What is the reason behind the nurse's instruction?

The nurse should insist that the helper not hold the tube away from the lips or nares. Doing so increases the risk of tube movement and accidental extubation. An adhesive can damage the skin. The tape should be carefully removed to prevent damage to the skin. The use of a commercially available endotracheal tube holder facilitates easy and fast insertion. Applying clean gloves helps to reduce transmission of microorganisms. pg. 916

While performing suctioning, the nurse avoids applying suction pressure while inserting the catheter. What is the rationale behind this?

The nurse should never apply suction pressure while inserting the catheter. If suction pressure is applied during insertion, trauma to the lung mucosa may occur. The risk of hypotension is decreased when the nurse refrains from too-frequent suctioning. To minimize the risk of triggering the gag reflex, the nose is the preferred route for suctioning. To remove secretions that are adhered to the sides of the endotracheal tubes, the nurse should rotate the catheter. pg. 895

While performing endotracheal tube care, which assessment findings contraindicate removal of the oral airway?

The nurse should not remove oral airway if the patient is actively biting or moving the endotracheal tube with the tongue that may cause complications. Deeply breathing may help in providing the baseline for ventilation and ease of breathing but may not be a contraindication to remove oral airway. The importance of trying not to cough or controlling cough is taught to the patient who is on endotracheal tube care as coughing may cause serious complications in the patient who is receiving endotracheal tube care. The supine position or a semi-Fowler position is comfortable for both the patient and nurse to provide endotracheal tube care. Patient attaining this position may not be contraindicated to remove the oral airway. p. 916

The nurse is caring for a patient who was admitted to the hospital with a diagnosis of left-sided heart failure. The health care provider asks the nurse to provide continuous positive airway pressure (CPAP) for this patient. What could be the primary motive behind giving CPAP to this patient?

The patient has left-sided heart failure, which can lead to the pooling of blood in the pulmonary circulation. Pulmonary congestion puts pressure on the alveolar walls, forcing them to collapse. Continuous positive airway pressure (CPAP) helps keep the alveoli in an inflated position, thereby preventing them from collapsing. CPAP reduces pulmonary edema by forcing fluid out of the lungs. CPAP plays no role in improving the contractility of the cardiac musculature. p. 897

While caring for a patient who has a chest tube, the nurse places the patient in a high-Fowler's position. What is the reason behind this nursing action?

The patient who has a chest tube is positioned in a high-Fowler's position to promote draining of fluids from the chest in conditions such as hemothorax and emphysema. The patient is positioned in a semi-Fowler's position to evacuate air from the lungs in conditions such as pneumothorax. The tubing is adjusted to hang in a straight line from the top of the mattress to drainage chamber to prevent blood from accumulation. Stripping the tube should be avoided to prevent excessive negative intrapleural pressure. p. 924

On the first postoperative day, a patient who underwent a cholecystectomy complains of shortness of breath. The x-ray indicates that the patient has atelectasis. Which intervention could have prevented this complication?

The patient's symptoms and signs indicate atelectasis. Patients who undergo abdominal surgery are at increased risk of atelectasis postoperatively. Incentive spirometry encourages these patients to practice deep breathing by providing visual feedback about inspiratory volume. This expands the alveoli and prevents lung collapse. Early mobilization of the patient does not prevent atelectasis but is important to prevent such complications as pneumonia and deep vein thrombosis (DVT). Nebulization or administration of oxygen will not prevent lung collapse. pg. 896

A family of four approaches the community nurse for a pneumococcal vaccine. The grandfather is 70 years old; the mother, 46; the daughter 22; and the son, 18. The son is a smoker. None of the family has asthma or other chronic illnesses. Which family member should receive the pneumococcal vaccine?

The pneumococcal vaccine is recommended for all adults older than 65 years; therefore, the grandfather should receive the vaccine. It is also indicated for patients with a history of asthma, smokers, and patients having any chronic illnesses irrespective of their age. Therefore, the son should also receive the pneumococcal vaccine. The mother and daughter do not need the vaccine, because they are younger than 65 years and do not have asthma or any other chronic illness. p. 891

While caring for a patient with an artificial airway, which action by the nurse is least likely to be preferred in this condition?

The skill of performing artificial airway care cannot be delegated to nursing assistive personnel. This action by the nursing student indicates a need for correction. The nursing student can report any obstruction observed in the tracheostomy tube. This task can also be delegated to nursing assistive personnel if the patient has a well-established tracheostomy tube. The nursing student should auscultate lung sounds that can provide a baseline measure of ventilation and ease of breathing. Tasks such as reporting any unexpected drainage or secretions from the tracheostomy or any change in color of the stoma can be performed by nursing assistive personnel. pg. 915

While preparing a patient for an endotracheal tube, the nurse uses a Yankauer suction tip. What is the rationale for this nursing action?

The transmission of microorganisms to linens and bedclothes during endotracheal suctioning may lead to infection. Using a Yankauer suction tip to clear the secretions during endotracheal tube care helps to maintain asepsis. Explaining the importance of the patient's participation helps to reduce anxiety and encourages cooperation. Obtaining staff nurse assistance during the procedure helps to reduce the risk of accidental extubation. To facilitate procedure completion without causing discomfort, the nurse should assist the patient to sleep in a supine or semi-Fowler's position. p. 916

What type of suctioning involves instilling normal saline and stimulating the patient to cough to loosen airway secretions?

Tracheal suctioning is used to clear the trachea. In this procedure, normal saline is instilled and used to stimulate patients to cough. As a result, the airway secretions are loosened. Oropharyngeal and nasopharyngeal suctioning is used when the when the patient can cough and is unable to clear the secretions. Pharyngeal suctioning is used to clear the pharynx and keep it free from infectious bacteria. Orotracheal and nasotracheal suctioning is necessary when a patient who has pulmonary secretions is unable to manage secretions by coughing and does not have an artificial airway. p. 900

Which complication may be caused by movement of the endotracheal tube?

Tracheal trauma may occur if the endotracheal tube moves. An underinflated cuff increases the patient's risk of aspiration. Retaining secretions may predispose the patient to atelectasis. Pneumothorax may not be a complication due to movement of the endotracheal tube.

While caring for a patient who has a chest tube, the nurse finds air leaks unrelated to the patient's respiration. Which primary nursing action is indicated to control the critical situation?

Unexpected air leaks may be the complication that arises during the chest tube aeration. Such conditions can be bought under control either by tightening all the connections between the patient and the drainage system or by notifying the health care provider immediately to change the drainage system. Continuous bubbling in the water-seal chamber can be controlled by reinforcing the dressing. Tension pneumothorax may be controlled by applying a Heimlich valve for emergency release of air that is accumulated in the intrapleural space. A leak between the patient and water seal can be resolved by unclamping the chest tube. p. 926

While caring for a patient with chest tubes, the nurse asks the patient to rate the level of comfort on scale of 0 to 10. What could be the rationale behind this?

While caring for a patient with chest tubes, the nurse asks the patient to rate the level of comfort on the scale of 0 to 10. Based on the rating the nurse can identify if the patient has developed atelectasis or pneumonia. The nurse should evaluate cardiopulmonary status in a patient who is undergoing suctioning in order to prevent the risk of hypoxia. Epistaxis and skin abrasions are the unexpected outcomes of chest tubes. Epistaxis is prevented by assessing the patient's fluid status. Skin abrasion can be prevented by adjusting the tightness of an elastic strap. pg. 926

What is the reason for heart failure after myocardial infarction (MI)?

p. 874

Which patients are at risk of hyperventilation?

pg. 877

Which intervention in a patient with a tracheostomy pulls mucus and other contaminants from the stoma?

pg. 920