Artificial Airways Practice Questions
What range of pressure within the endotracheal tube cuff does the nurse maintain to prevent both injury and aspiration? -25 to 30 mm Hg -15 to 20 mm Hg -10 to 15 mm Hg -20 to 25 mm Hg
-20 to 25 mm Hg Explanation: Usually the pressure is maintained at <25 mm HG (30 cm H2O) water pressure to prevent injury and at >20 mm HG (24 cm H2O) water pressure to prevent aspiration. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis, whereas low cuff pressure can increase the risk of aspiration pneumonia. A water pressure of 10-15 or 15-20 mm Hg would indicate that the cuff is underinflated. A water pressure of 25-30 mm Hg would indicate that the cuff is overinflated.
The nurse is assisting with the removal of an oral endotracheal tube. Place in order the actions the nurse will take to provide care to the client. Use all options. 1 Remove the tube while suctioning the airway as it is removed 2 Instruct the client to inhale. 3 Remove tape. 4 Explain the procedure. 5 Place a self-inflating bag and mask at the bedside. 6 Insert a new sterile suction catheter inside the tube. 7 Provide a few breaths of 100% oxygen. 8 Suction the tracheobronchial tree and oropharynx. 9 Deflate the cuff.
4 Explain the procedure. 5 Place a self-inflating bag and mask at the bedside. 8 Suction the tracheobronchial tree and oropharynx. 3 Remove tape. 9 Deflate the cuff. 7 Provide a few breaths of 100% oxygen. 6 Insert a new sterile suction catheter inside the tube. 2 Instruct the client to inhale. 1 Remove the tube while suctioning the airway as it is removed Explanation: When removing the endotracheal tube, the procedure is first explained to the client. A self-inflating bag and mask is to be at the bedside in case the client needs ventilatory assistance after the tube is removed. The tracheobronchial tree and oropharynx are then suctioned before removing the tape. The cuff is then deflated on the tube and the client is provided with a few breaths of 100% oxygen. Next a new sterile suction catheter is inserted inside of the tube. The client is then instructed to inhale a deep breath, and at the peak of the inspiration, the tube is removed while suctioning the airway through the tube as it is pulled out.
A client in the ICU has had an endotracheal tube in place for 3 weeks. The health care provider has ordered that a tracheostomy tube be placed. The client's family wants to know why the endotracheal tube cannot be left in place. What would be the nurse's best response? -"It is much harder to breathe through an endotracheal tube than a tracheostomy." -"The physician may feel that mechanical ventilation will have to be used long-term." -"Long-term use of an endotracheal tube diminishes the normal breathing reflex." -"When an endotracheal tube is left in too long it can damage the lining of the windpipe."
-"When an endotracheal tube is left in too long it can damage the lining of the windpipe." Explanation: Endotracheal intubation may be used for no longer than 2 to 3 weeks, by which time a tracheostomy must be considered to decrease irritation of and, trauma to, the tracheal lining, to reduce the incidence of vocal cord paralysis (secondary to laryngeal nerve damage), and to decrease the work of breathing. The need for long-term ventilation would not be the primary rationale for this change in treatment. Endotracheal tubes do not diminish the breathing reflex.
A nurse is reviewing a client's X-ray. The X-ray shows an endotracheal (ET) tube placed 3/4" (2 cm) above the carina and reveals nodular lesions and patchy infiltrates in the upper lobe. Which interpretation of the X-ray is accurate? -A disease process is present. -The X-ray is inconclusive. -The ET tube must be pulled back. -The ET tube must be advanced.
-A disease process is present. Explanation: This X-ray suggests tuberculosis. An ET tube that's 3/4" above the carina is at an adequate level in the trachea. There's no need to advance it or pull it back.
The nurse is preparing to suction a client with an endotracheal tube. What should be the nurse's first step in the suctioning process? -Explain the suctioning procedure to the client and reposition the client. -Assess the client's lung sounds and SaO2 via pulse oximeter. -Turn on suction source at a pressure not exceeding 120 mm Hg. -Perform hand hygiene and don nonsterile gloves, goggles, gown, and mask.
-Assess the client's lung sounds and SaO2 via pulse oximeter. Explanation: Assessment data indicate the need for suctioning and allow the nurse to monitor the effect of suction on the client's level of oxygenation. Explaining the procedure, performing hand hygiene, and turning on the suction source are interventions that should follow assessment. As with all interventions, assessment should be performed first.
The nurse is caring for a client with an endotracheal tube who is on a ventilator. When assessing the client, the nurse knows to maintain what cuff pressure to maintain appropriate pressure on the tracheal wall? -Between 15 and 20 mm Hg -Between 25 and 30 mm Hg -Between 20 and 25 mm Hg -Between 10 and 15 mm Hg
-Between 20 and 25 mm Hg Explanation: Complications can occur from pressure exerted by the cuff on the tracheal wall. Cuff pressures should be maintained between 20 and 25 mm Hg.
A client being mechanically ventilated through an endotracheal tube for 14 days has a percutaneous tracheostomy inserted at the bedside. Which interventions will the nurse anticipate will be included in the client's plan of care? Select all that apply. -Use clean technique for tracheostomy care -Suction as necessary -Monitor oxygen saturation -Change tape and dressing as needed -Check cuff pressure every 8 hours
-Suction as necessary -Monitor oxygen saturation -Change tape and dressing as needed -Check cuff pressure every 8 hours Explanation: Endotracheal intubation may be used for no longer than 14 to 21 days, by which time a tracheostomy must be considered to decrease irritation of and trauma to the tracheal lining, and to reduce the incidence of vocal cord paralysis. For a client who is intubated and mechanically ventilated, a newer surgical technique referred to as a percutaneous tracheostomy can be performed at the bedside with the use of local anesthesia and sedation and analgesia. Once the tracheostomy is placed, nursing care includes suctioning as necessary, monitoring oxygen saturation, checking cuff pressure every 8 hours, and changing the tape and dressing as needed. Care of the tracheostomy is completed using sterile and not clean technique.
Which statements would be considered appropriate interventions for a client with an endotracheal tube? Select all that apply. -The cuff is deflated before the tube is removed. -Cuff pressures should be checked every 6 to 8 hours. -Humidified oxygen should always be introduced through the tube. -Routine cuff deflation is recommended. -Suctioning the oropharynx prn is not recommended.
-The cuff is deflated before the tube is removed. -Cuff pressures should be checked every 6 to 8 hours. -Humidified oxygen should always be introduced through the tube. Explanation: The cuff is deflated before the endotracheal tube is removed. Cuff pressures should be checked every 6 to 8 hours. And must be maintained at 15- 2 mm Hg to prevent excess pressure , High cuff pressure leads to tracheal bleeding and other complications. Humidified oxygen should always be introduced through the tube. Routine cuff deflation is not recommended because of the increased risk for aspiration and hypoxia. It is recommended to provide oral hygiene and suction the oropharynx whenever necessary, the cough , glottic, pharyngeal ,and laryngeal reflexes are suppressed and the nurse needs to keep all airways clear for the client.
A client in acute respiratory distress is brought to the emergency department. After endotracheal (ET) intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the ET tube, the nurse hyperventilates and hyperoxygenates the client. What is the rationale for these interventions? -They help prevent cardiac arrhythmias. -They help prevent pneumothorax. -They help prevent pulmonary edema. -They help prevent subcutaneous emphysema.
-They help prevent cardiac arrhythmias. Explanation: ET suctioning removes oxygen, lowering the partial pressure of arterial oxygen; this, in turn, may induce a cardiac arrhythmia. Hyperventilating and hyperoxygenating the client before and during (or after) suctioning helps prevent this complication. Subcutaneous emphysema occurs when air from the pleural cavity leaks into subcutaneous tissue; it isn't a complication associated with suctioning. Hyperventilation and hyperoxygenation can't prevent a pneumothorax because this condition itself indicates air in the pleural space. Pulmonary edema is associated with cardiac dysfunction, not ET suctioning.
A client is being mechanically ventilated with an oral endotracheal tube in place. The nurse observes that the cuff pressure is 28 mm Hg. The nurse is aware of what complications that can be caused by this pressure? Select all that apply. -Tracheal ischemia -Tracheal aspiration -Pressure necrosis -Tracheal bleeding -Hypoxia
-Tracheal ischemia -Pressure necrosis -Tracheal bleeding Explanation: Complications can occur from pressure exerted by the cuff on the tracheal wall. Cuff pressures should be maintained between 20 and 25 mm Hg. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis, whereas low cuff pressure can increase the risk of aspiration pneumonia. Routine deflation of the cuff is not recommended because of the increased risk of aspiration and hypoxia.
A nurse is caring for a client who has a tracheostomy tube and who is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by: -using a cuffed tracheostomy tube. -suctioning the tracheostomy tube frequently. -keeping the tracheostomy tube plugged. -using the minimal-leak technique with cuff pressure less than 25 cm H2O.
-using the minimal-leak technique with cuff pressure less than 25 cm H2O. Explanation: To prevent tracheal dilation, a minimal-leak technique should be used and the pressure should be kept at less than 25 cm H2O. Suctioning is vital but won't prevent tracheal dilation. Use of a cuffed tube alone won't prevent tracheal dilation. The tracheostomy shouldn't be plugged to prevent tracheal dilation. This technique is used when weaning the client from tracheal support.
The nurse is providing tracheostomy care for a client. Place the following steps in the order the nurse should perform them. 1 Clean around the stoma with an applicator moistened with normal saline. 2 Open the tracheostomy kit without contaminating the contents. Don sterile gloves—keep the dominant hand sterile. Pour hydrogen peroxide and normal saline into respective containers. 3 Rinse the cleaned cannula with normal saline. Tap the cannula and wipe the excess solution with sterile gauze. 4 Position client in a supine or low Fowler position. 5 Place a sterile dressing around the tracheostomy tube. Change the tracheostomy ties by placing the new ones on first and removing the soiled ones last. Tie the new ends securely, but not tightly, at the side of the neck. 6 Unlock the inner cannula by turning it counterclockwise. Remove it and place in hydrogen peroxide. Clean the inside and outside of the cannula with pipe cleaners. 7 Using a clean glove, remove the soiled stomal dressing and discard it, glove and all, in an appropriate receptacle. 8 Replace the inner cannula and turn it clockwise within the outer cannula.
4 Position client in a supine or low Fowler position. 7 Using a clean glove, remove the soiled stomal dressing and discard it, glove and all, in an appropriate receptacle. 2 Open the tracheostomy kit without contaminating the contents. Don sterile gloves—keep the dominant hand sterile. Pour hydrogen peroxide and normal saline into respective containers. 6 Unlock the inner cannula by turning it counterclockwise. Remove it and place in hydrogen peroxide. Clean the inside and outside of the cannula with pipe cleaners. 3 Rinse the cleaned cannula with normal saline. Tap the cannula and wipe the excess solution with sterile gauze. 8 Replace the inner cannula and turn it clockwise within the outer cannula. 1 Clean around the stoma with an applicator moistened with normal saline. 5 Place a sterile dressing around the tracheostomy tube. Change the tracheostomy ties by placing the new ones on first and removing the soiled ones last. Tie the new ends securely, but not tightly, at the side of the neck. Explanation: The nurse should position client in a supine or low Fowler position. Using a clean glove, the nurse should remove the soiled stomal dressing and discard it, glove and all, in an appropriate receptacle. The nurse should then open the tracheostomy kit without contaminating the contents. The nurse should don sterile gloves, keeping the dominant hand sterile. Next, the nurse should pour hydrogen peroxide and normal saline into respective containers. The nurse should then unlock the inner cannula by turning it counterclockwise, then removing it and placing it in hydrogen peroxide. The nurse should clean the inside and outside of the cannula with pipe cleaners. Next, the nurse should rinse the cleaned cannula with normal saline. The nurse should then tap the cannula and wipe the excess solution with sterile gauze. Next, the nurse should replace the inner cannula and turn it clockwise within the outer cannula. The nurse should then clean around the stoma with an applicator moistened with normal saline. Following this, the nurse should place a sterile dressing around the tracheostomy tube and change the tracheostomy ties by placing the new ones on first and removing the soiled ones last. Finally, the nurse should tie the new ends securely, but not tightly, at the side of the neck. The nurse should perform hand hygiene before, during, and after the procedure.