Ch. 21

A thoracentesis is performed to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes. What does serous fluid indicate? Trauma Infection Cancer Emphysema

Cancer Explanation: A thoracentesis may be performed to obtain a sample of pleural fluid or to biopsy a specimen from the pleural wall for diagnostic purposes. Serous fluid may be associated with cancer, inflammatory conditions, or heart failure. Blood fluid typically suggests trauma. Purulent fluid is diagnostic for infection. Complications that may follow a thoracentesis include pneumothorax and subcutaneous emphysema. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Respiratory Care Modalities, p. 540.

The nurse is caring for a client following a thoracotomy. Which finding requires immediate intervention by the nurse? Heart rate, 112 bpm Moderate amounts of colorless sputum Pain of 5 on a 1-to-10 scale Chest tube drainage, 190 mL/hr

Chest tube drainage, 190 mL/hr Explanation: The nurse should monitor and document the amount and character of drainage every 2 hours. The nurse must notify the primary provider if drainage is ≥150 mL/hr. The other findings are normal following a thoracotomy and no intervention would be required. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Respiratory Care Modalities, Chart 21-20, p. 544.

The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying? Anemic hypoxia Circulatory hypoxia Histotoxic hypoxia Hypoxemic hypoxia

Circulatory hypoxia Explanation: Given the vital signs, this client appears to be in shock. Circulatory hypoxia results from inadequate capillary circulation and may be caused by decreased cardiac output, local vascular obstruction, low-flow states such as shock, or cardiac arrest. Although tissue partial pressure of oxygen (PO2) is reduced, arterial oxygen (PaO2) remains normal. Circulatory hypoxia is corrected by identifying and treating the underlying cause. The low blood pressure is consistent with circulatory hypoxia but not consistent with the other options. Anemic hypoxia is a result of decreased effective hemoglobin concentration. Histotoxic hypoxia occurs when a toxic substance interferes with the ability of tissues to use available oxygen. Hypoxemic hypoxia results from a low level of oxygen in the blood. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 511.

The nurse is caring for a client in the ICU who is receiving mechanical ventilation. Which nursing measure is implemented in an effort to reduce the client's risk of developing ventilator-associated pneumonia (VAP)? Cleaning the client's mouth with chlorhexidine daily Maintaining the client in a high Fowler's position Ensuring that the client remains sedated while intubated Turning and repositioning the client every 4 hours

Cleaning the client's mouth with chlorhexidine daily Explanation: The five key elements of the VAP bundle include elevation of the head of the bed (30 to 45 degrees [semi-Fowler's position)], daily "sedation vacations," and assessment of readiness to extubate; peptic ulcer disease prophylaxis (with histamine-2 receptor antagonists); deep venous thrombosis prophylaxis; and daily oral care with chlorhexidine (0.12% oral rinses). The client should be turned and repositioned every 2 hours to prevent complications of immobility and atelectasis and to optimize lung expansion. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Respiratory Care Modalities, Chart 21-11, p. 530.

A client with asthma is prescribed an inhaled corticosteroid. For which reason will the nurse recommend that a small volume nebulizer (SVN) be used to provide the medication to the client? Medication requires rapid inhalation Client has rheumatoid arthritis Client needs to exhale through the device Client needs to hold breath after inhalation

Client has rheumatoid arthritis Explanation: A small volume nebulizer (SVN) is used to administer corticosteroids in addition to other medications. It requires slow tidal breathing with occasional deep breaths and administers the medication through a tight fitting facemask which is ideal for clients unable to use a mouthpiece. This delivery system is less dependent on the client's coordination and cooperation. A client with rheumatoid arthritis has swelling of the hands and would have difficulty using another delivery system for the medication. The SVN does not require rapid inhalation. Exhalation is not done through the device. The client does not need to hold the breath after inhalation.

A client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the mosteffective for this client? Surgery to remove the tonsils and adenoids Medications to assist the patient with sleep at night Continuous positive airway pressure (CPAP) Bi-level positive airway pressure (BiPAP)

Continuous positive airway pressure (CPAP) Explanation: CPAP provides positive pressure to the airways throughout the respiratory cycle. Although it can be used as an adjunct to mechanical ventilation with a cuffed endotracheal tube or tracheostomy tube to open the alveoli, it is also used with a leak-proof mask to keep alveoli open, thereby preventing respiratory failure. CPAP is the most effective treatment for obstructive sleep apnea because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. CPAP is used for clients who can breathe independently. BiPAP is most often used for clients who require ventilatory assistance at night, such as those with severe COPD or sleep apnea. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 526.

The nurse is using an in-line suction kit to suction a patient who is intubated and on a mechanical ventilator. What benefits does inline suction have for the patient? (Select all that apply.) Decreases hypoxemia Decreases patient anxiety Sustains positive end expiratory pressure (PEEP) Increases oxygen consumption Prevents aspiration

Decreases hypoxemia Decreases patient anxiety Sustains positive end expiratory pressure (PEEP) Explanation: An in-line suction device allows the patient to be suctioned without being disconnected from the ventilator circuit. In-line suctioning (also called closed suctioning) decreases hypoxemia, sustains PEEP, and can decrease patient anxiety associated with suctioning (Sole et al., 2013). Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 525.

The nurse hears the patient's ventilator alarm sound and attempts to find the cause. What is the priority action of the nurse when the cause of the alarm is not able to be determined? Call respiratory therapy and wait until they arrive to determine what is happening. Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved. Stop the ventilator by pressing the off button, wait 15 seconds, and then turn it on again to see if the alarm stops. Suction the patient since the patient may be obstructed by secretions.

Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved. Explanation: If the cause of an alarm cannot be determined, the nurse should disconnect the patient from the ventilator and manually ventilate the patient, because leaving the patient on the mechanical ventilator may be dangerous. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 529.

After suctioning a tracheostomy tube, the nurse assesses the client to determine the effectiveness of the suctioning. Which findings indicate that the airway is now patent? A respiratory rate of 28 breaths/minute with accessory muscle use Effective breathing at a rate of 16 breaths/minute through the established airway Increased pulse rate, rapid respirations, and cyanosis of the skin and nail beds Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds

Effective breathing at a rate of 16 breaths/minute through the established airway Explanation: Proper suctioning should produce a patent airway, as demonstrated by effective breathing through the airway at a normal respiratory rate of 12 to 20 breaths/minute. The other options suggest ineffective suctioning. A respiratory rate of 28 breaths/minute and accessory muscle use may indicate mild respiratory distress. Increased pulse rate, rapid respirations, and cyanosis are signs of hypoxia. Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds indicate respiratory secretion accumulation. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 532.

A client is recovering from thoracic surgery needed to perform a right lower lobectomy. Which of the following is the most likely postoperative nursing intervention? Encourage coughing to mobilize secretions. Restrict intravenous fluids for at least 24 hours. Make sure that a thoracotomy tube is linked to open chest drainage. Assist with positioning the client on the right side.

Encourage coughing to mobilize secretions. Explanation: The client is encouraged to cough frequently to mobilize secretions. The client will be placed in the semi-Fowler's position. The chest tube is always attached to closed, sealed drainage to re-expand lung tissue and prevent pneumothorax. Restricting IV fluids in a client who is NPO while recovering from surgery would lead to dehydration. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 544.

A nurse is planning care for a client after a tracheostomy. One of the client's goals is to overcome verbal communication impairment. Which intervention should the nurse include in the care plan? Make an effort to read the client's lips to foster communication. Encourage the client's communication attempts by allowing him time to select or write words. Answer questions for the client to reduce his frustration. Avoid using a tracheostomy plug because it blocks the airway.

Encourage the client's communication attempts by allowing him time to select or write words. Explanation: The nurse should allow ample time for the client to respond and shouldn't speak for him. She should use as many aids as possible to assist the client with communicating and encourage the client when he attempts to communicate. When the client is ready, the nurse can use a tracheostomy plug to facilitate speech. Making an effort to read the client's lips and answering questions for the client are inappropriate. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, pp. 531-532.

A client is receiving mechanical ventilation. How frequently should the nurse auscultate the client's lungs to check for secretions? Every 30 to 60 minutes Every 1 to 2 hours Every 2 to 4 hours Every 4 to 6 hours

Every 2 to 4 hours Explanation: Continuous positive-pressure ventilation increases the production of secretions regardless of the patient's underlying condition. The nurse assesses for the presence of secretions by lung auscultation at least every 2 to 4 hours. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 531.

A client is postoperative and prescribed an incentive spirometer (IS). The nurse instructs the client to: Maintain a supine position to use the spirometer. Inhale and exhale rapidly with the spirometer. Expect coughing when using the spirometer properly. Use the spirometer twice every hour.

Expect coughing when using the spirometer properly. Explanation: When using an incentive spirometer, the client should be sitting or in the semi-Fowler's position. The client is to inhale, hold the breath for about 3 seconds, and then exhale slowly. Coughing occurs with the use of the incentive spirometer and is encouraged. The client should use the spirometer 10 times every hour while awake. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 516.

The nurse should monitor a client receiving mechanical ventilation for which of the following complications? Gastrointestinal hemorrhage Immunosuppression Increased cardiac output Pulmonary emboli

Gastrointestinal hemorrhage Explanation: Gastrointestinal hemorrhage occurs in approximately 25% of clients receiving prolonged mechanical ventilation. Other possible complications include incorrect ventilation, oxygen toxicity, fluid imbalance, decreased cardiac output, pneumothorax, infection, and atelectasis. Immunosuppression and pulmonary emboli are not direct consequences of mechanical ventilation. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 529.

The nurse is educating the patient in the use of a mini-nebulizer. What should the nurse encourage the patient to do? (Select all that apply.) Hold the breath at the end of inspiration for a few seconds. Cough frequently. Take rapid, deep breaths. Frequently evaluate progress. Prolong the expiratory phase after using the nebulizer.

Hold the breath at the end of inspiration for a few seconds. Cough frequently. Frequently evaluate progress. Explanation: The nurse instructs the patient to breathe through the mouth, taking slow, deep breaths, and then to hold the breath for a few seconds at the end of inspiration to increase intrapleural pressure and reopen collapsed alveoli, thereby increasing functional residual capacity. The nurse encourages the patient to cough and to monitor the effectiveness of the therapy. The nurse instructs the patient and family about the purpose of the treatment, equipment setup, medication additive, and proper cleaning and storage of the equipment. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 517.

A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition? Hypoxia Delirium Hyperventilation Semiconsciousness

Hypoxia Explanation: As the respiratory center in the brain becomes depressed, hypoxia occurs, producing wheezing, bradycardia, and a decreased respiratory rate. Delirium is a state of mental confusion characterized by disorientation to time and place. Hyperventilation (respiratory rate greater than that metabolically necessary for gas exchange) is marked by an increased respiratory rate or tidal volume, or both. Semiconsciousness is a state of impaired consciousness characterized by limited motor and verbal responses and decreased orientation. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, pp. 532-533.

A nurse is attempting to wean a client after 2 days on the mechanical ventilator. The client has an endotracheal tube present with the cuff inflated to 15 mm Hg. The nurse has suctioned the client with return of small amounts of thin white mucus. Lung sounds are clear. Oxygen saturation levels are 91%. What is the priority nursing diagnosis for this client? Impaired gas exchange related to ventilator setting adjustments Risk for trauma related to endotracheal intubation and cuff pressure Risk for infection related to endotracheal intubation and suctioning Impaired physical mobility related to being on a ventilator

Impaired gas exchange related to ventilator setting adjustments Explanation: All the nursing diagnoses are appropriate for this client. Per Maslow's hierarchy of needs, airway, breathing, and circulation are the highest priorities within physiological needs. The client has an oxygen saturation of 91%, which is below normal. This places impaired gas exchange as the highest prioritized nursing diagnosis. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 531.

Which finding would indicate a decrease in pressure with mechanical ventilation? Kinked tubing Increase in compliance Decrease in lung compliance Plugged airway tube

Increase in compliance Explanation: A decrease in pressure in the mechanical ventilator may be caused by an increase in compliance. Kinked tubing, decreased lung compliance, and a plugged airway tube cause an increase in peak airway pressure. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Respiratory Care Modalities, Table 21-2, p. 530.

The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique? Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes. Use aerosol sprays to deodorize the client's environment after postural drainage. Perform this measure with the client once a day. Administer bronchodilators and mucolytic agents following the sequence.

Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes. Explanation: Postural drainage is usually performed two to four times daily, before meals (to prevent nausea, vomiting, and aspiration) and at bedtime. Prescribed bronchodilators, water, or saline may be nebulized and inhaled before postural drainage to dilate the bronchioles, reduce bronchospasm, decrease the thickness of mucus and sputum, and combat edema of the bronchial walls. The nurse instructs the client to remain in each position for 10 to 15 minutes and to breathe in slowly through the nose and out slowly through pursed lips to help keep the airways open so that secretions can drain while in each position. If the sputum is foul-smelling, it is important to perform postural drainage in a room away from other patients or family members. (Deodorizers may be used to counteract the odor. Because aerosol sprays can cause bronchospasm and irritation, they should be used sparingly and with caution.) Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 519.

Which ventilator mode provides a combination of mechanically assisted breaths and spontaneous breaths? Intermittent mandatory ventilation (IMV) Assist control Synchronized intermittent mandatory ventilation (SIMV) Pressure support

Intermittent mandatory ventilation (IMV) Explanation: IMV provides a combination of mechanically assisted breaths and spontaneous breaths. Assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate. SIMV delivers a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the client can breathe spontaneously with no assistance from the ventilator for those extra breaths. Pressure support ventilation assists SIMV by applying a pressure plateau to the airway throughout the client-triggered inspiration to decrease resistance within the tracheal tube and ventilator tubing. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Respiratory Care Modalities, p. 528.

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside? Tracheostomy cleaning kit Water-seal chest drainage set-up Manual resuscitation bag Oxygen analyzer

Manual resuscitation bag Explanation: The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit at the bedside isn't necessary. Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate the effectiveness of ventilation, this equipment is less important than the manual resuscitation bag. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 533.

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside? Select all that apply. Tracheostomy cleaning kit Water-seal chest drainage set-up Manual resuscitation bag Pulse oximeter Hemostat

Manual resuscitation bag Pulse oximeter Explanation: The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. The nurse needs to keep an oxygen analyzer (pulse oximeter) on hand to evaluate the effectiveness of ventilation. Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit or hemostat at the bedside isn't necessary. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Respiratory Care Modalities, p. 509, 533.

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan? Measuring and documenting the drainage in the collection chamber Maintaining continuous bubbling in the water-seal chamber Keeping the collection chamber at chest level Stripping the chest tube every hour

Measuring and documenting the drainage in the collection chamber Explanation: The nurse should regularly measure and document the amount of chest tube drainage to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected. The nurse should keep the collection chamber below chest level to allow fluids to drain into it. The nurse shouldn't strip chest tubes because doing so may traumatize the tissue or dislodge the tube. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 542.

A young male client has muscular dystrophy. His PaO2 is 42 mm Hg with a FiO2 of 80%. Which of the following treatments would be least invasive and most appropriate for this client? Negative-pressure ventilator Positive-pressure ventilator Continuous positive airway pressure (CPAP) Bilevel positive airway pressure (Bi-PAP)

Negative-pressure ventilator Explanation: This client needs ventilatory support. His PaO2 is low despite receiving a high dose of oxygen. The iron lung or drinker respiratory tank is an example of a negative-pressure ventilator. This type of ventilator is used mainly with chronic respiratory failure associated with neurological disorders, such as muscular dystrophy. It does not require intubation of the client. The most common ventilator is the positive-pressure ventilator, but this involves intubation with an endotracheal tube or tracheostomy. CPAP is used for obstructive sleep apnea. Bi-PAP is used for those with severe COPD or sleep apnea who require ventilatory assistance at night. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 525.

A client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which oxygen delivery method would give the greatest level of inspired oxygen? Simple mask Nonrebreather mask Face tent Nasal cannula

Nonrebreather mask Explanation: A nonrebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask, face tent, and nasal cannula — deliver lower levels of FIO2. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 514.

Which oxygen administration device has the advantage of providing a high oxygen concentration? Nonrebreathing mask Venturi mask Catheter Face tent

Nonrebreathing mask Explanation: Nonrebreathing masks provide high oxygen concentrations but usually fit poorly. A Venturi mask provides low levels of supplemental oxygen. A catheter is an inexpensive device that provides a variable fraction of inspired oxygen and may cause gastric distention. A face tent provides a fairly accurate fraction of inspired oxygen but is bulky and uncomfortable; it would not be the device of choice to provide a high oxygen concentration. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Respiratory Care Modalities, p. 514.

A client has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the client complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect? Oxygen-induced hypoventilation Oxygen toxicity Oxygen-induced atelectasis Hypoxia

Oxygen toxicity Oxygen toxicity may occur when too high a concentration of oxygen (greater than 50%) is administered for an extended period (longer than 48 hours) (Urden, Stacy, & Lough, 2014). Signs and symptoms of oxygen toxicity include substernal discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxemia, alveolar atelectasis, and alveolar infiltrates evident on chest x-rays. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 512.

The nurse is teaching a client the proper technique for diaphragmatic breathing. Place the steps for this procedure in the correct sequence. Place one hand on the abdomen and the other hand on the middle of the chest to increase awareness of the position of the diaphragm and its function in breathing. Breathe in slowly and deeply through the nose, letting the abdomen protrude as far as possible. Breathe out through pursed lips while tightening the abdominal muscles. Press firmly inward and upward on the abdomen while breathing out. Repeat for 1 minute; follow with a 2-minute rest period.

Place one hand on the abdomen and the other hand on the middle of the chest to increase awareness of the position of the diaphragm and its function in breathing. Breathe in slowly and deeply through the nose, letting the abdomen protrude as far as possible. Breathe out through pursed lips while tightening the abdominal muscles. Press firmly inward and upward on the abdomen while breathing out. Repeat for 1 minute; follow with a 2-minute rest period. The correct sequence for diaphragmatic breathing is as follows: (1) Place one hand on the abdomen (just below the ribs) and the other hand on the middle of the chest to increase awareness of the position of the diaphragm and its function in breathing. (2) Breathe in slowly and deeply through the nose, letting the abdomen protrude as far as possible. (3) Breathe out through pursed lips while tightening (contracting) the abdominal muscles. (4) Press firmly inward and upward on the abdomen while breathing out. (5) Repeat for 1 minute; follow with a 2-minute rest period. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Respiratory Care Modalities, Chart 21-4, p. 517.

A nurse is transporting a client with chest tubes to a treatment room. The chest tube becomes disconnected and falls between the bed rail. What is the priority action by the nurse? Immediately reconnect the chest tube to the drainage apparatus. Clamp the chest tube close to the connection site. Place the chest tube in sterile water. Notify the health care provider.

Place the chest tube in sterile water. Explanation: If the client is lying on a stretcher and must be transported to another area, place the drainage system below the chest level. If the tubing disconnects, place the end of the chest tube in sterile water. Reattaching the chest tube to the drainage system is a source for infection. Do not clamp the chest tube during transport. Notifying the health care provider will not help the client in the situation. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 542.

In general, chest drainage tubes are not indicated for a client undergoing which procedure? Lobectomy Pneumonectomy Wedge resection Segmentectomy

Pneumonectomy Explanation: Usually no drains are used in pneumonectomy because the accumulation of fluid in the empty hemothorax prevents mediastinal shift. With lobectomy, two chest tubes are usually inserted for drainage, the upper tube for air and the lower tube for fluid. With wedge resection, the pleural cavity usually is drained because of the possibility of an air or blood leak. With segmentectomy, drains are usually used because of the possibility of an air or blood leak. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Respiratory Care Modalities, Chart 21-17, p. 538.

A client with a chronic lung disease is prescribed postural drainage. Place in order the nurse's actions to perform this procedure. Use all options. Plan to do the procedure before a meal. Provide medication to loosen secretions before the procedure. Obtain an emesis basin, sputum cup, and paper tissues. Instruct client to breathe in through the nose and out through pursed lips. Place client in position to drain the lower lobes for 10 to 15 minutes and then cough. Place client in position to drain the middle lobe for 10 to 15 minutes and then cough. Place client in position to drain the upper lobes for 10 to 15 minutes and then cough.

Postural drainage allows the force of gravity to assist in the removal of bronchial secretions. The secretions drain from the affected bronchioles into the bronchi and trachea and are removed by coughing or suctioning. Postural drainage is usually performed 2 to 4 times daily, before meals (to prevent nausea, vomiting, and aspiration) and at bedtime. Prescribed bronchodilators, mucolytic agents, water, or saline may be nebulized and inhaled before postural drainage to dilate the bronchioles, reduce bronchospasm, decrease the thickness of mucus and sputum, and combat edema of the bronchial walls. The client is provided with an emesis basin, sputum cup, and paper tissues. The nurse instructs the client to breathe in slowly through the nose and out slowly through pursed lips to help keep the airways open so that secretions can drain. The recommended sequence starts with positions to drain the lower lobes, followed by positions to drain the upper lobe and the client needs to remain in each position for 10 to 15 minutes. The client should cough to remove secretions when the position is changed.

The nurse is caring for a client who is intubated for mechanical ventilation. Which intervention(s) will the nurse implement to reduce the client's risk of injury? Select all that apply. Provide oral hygiene. Assess for a cuff leak. Reduce pulling on ventilator tubing. Monitor cuff pressure every 8 hours. Position with head above the stomach level.

Provide oral hygiene. Assess for a cuff leak. Reduce pulling on ventilator tubing. Monitor cuff pressure every 8 hours. Position with head above the stomach level. Explanation: Maintaining the endotracheal or tracheostomy tube is an essential part of airway management. Oral hygiene is provided frequently because the oral cavity is a primary source of lung contamination in the client who is intubated. Assessing for a leak from the cuff of the endotracheal tube needs to be done at the same time as providing other respiratory care. Ventilator tubing should be positioned so that there is minimal pulling or distortion of the tube in the trachea which reduces the risk of trauma to the trachea. Cuff pressure is monitored every 8 hours to maintain the pressure at 20 to 25 mm Hg. The head of the bed should be higher than the stomach to reduce the risk of aspiration.

Positive end-expiratory pressure (PEEP) therapy has which effect on the heart? Bradycardia Tachycardia Increased blood pressure Reduced cardiac output

Reduced cardiac output Explanation: PEEP reduces cardiac output by increasing intrathoracic pressure and reducing the amount of blood delivered to the left side of the heart. It doesn't affect heart rate, but a decrease in cardiac output may reduce blood pressure, commonly causing compensatory tachycardia, not bradycardia. However, the resulting tachycardia isn't a direct effect of PEEP therapy itself. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 512.

A nurse is weaning a client from mechanical ventilation. Which nursing assessment finding indicates the weaning process should be stopped? Respiratory rate of 16 breaths/minute Oxygen saturation of 93% Runs of ventricular tachycardia Blood pressure remains stable

Runs of ventricular tachycardia Explanation: Ventricular tachycardia indicates that the client isn't tolerating the weaning process. The weaning process should be stopped before lethal ventricular arrhythmias occur. A respiratory rate of 16 breaths/minute and an oxygen saturation of 93% are normal findings. The client's blood pressure remains stable, so the weaning can continue. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 536.

A client seeks medical attention for a new onset of fatigue and changes in coordination. Which additional assessment finding indicates to the nurse that the client is demonstrating signs of low oxygenation? Select all that apply. Cough Shortness of breath Drowsiness Impaired thought process Agitation

Shortness of breath Impaired thought process Agitation Explanation: A change in the client's respiratory rate or pattern may be one of the earliest indicators of the need for oxygen therapy. These changes may result from hypoxemia or hypoxia. Severe hypoxia can be life threatening. The signs and symptoms signaling the need for supplemental oxygen may depend on how suddenly this need develops. The client has new onset of symptoms so the low oxygenation will be associated with acute hypoxia. With acute hypoxia, changes occur in the central nervous system because the neurologic centers are very sensitive to oxygen deprivation. Acute hypoxia that is newly presenting may manifest in signs such as shortness of breath, impaired thought process, and agitation. With long-standing or chronic hypoxia that is not manifesting as a new onset of symptoms, the client may demonstrate apathy, drowsiness, and delayed reaction time. The client may also demonstrate symptoms similar to alcohol intoxication such as impaired judgment. The presence of cough is not a manifestation of acute or chronic hypoxia.

A client with COPD has been receiving oxygen therapy for an extended period. What symptoms would be indicators that the client is experiencing oxygen toxicity? Select all that apply. Substernal pain Dyspnea Fatigue Mood swings Bradycardia

Substernal pain Dyspnea Fatigue Explanation: Oxygen toxicity can occur when clients receive too high a concentration of oxygen for an extended period. Symptoms include dyspnea, substernal pain, restlessness, fatigue, and progressive respiratory difficulty. Bradycardia and mood swings are not symptoms of oxygen toxicity. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 512.

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. Suction as necessary Monitor oxygen saturation Check cuff pressure every 8 hours Change tape and dressing as needed Use clean technique for tracheostomy care

Suction as necessary Monitor oxygen saturation Check cuff pressure every 8 hours Change tape and dressing as needed 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.

A client undergoes a tracheostomy after many failed attempts at weaning him from a mechanical ventilator. Two days after tracheostomy, while the client is being weaned, the nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first? Call the physician. Remove the malfunctioning cuff. Add more air to the cuff. Suction the client, withdraw residual air from the cuff, and reinflate it.

Suction the client, withdraw residual air from the cuff, and reinflate it. Explanation: After discovering an air leak, the nurse first should check for insufficient air in the cuff — the most common cause of a cuff air leak. To do this, the nurse should suction the client, withdraw all residual air from the cuff, and then reinflate the cuff to prevent overinflation and possible cuff rupture. The nurse should notify the physician only after determining that the air leak can't be corrected by nursing interventions, or if the client develops acute respiratory distress. The tracheostomy tube cuff can't be removed and replaced with a new one without changing the tracheostomy tube; also, removing the cuff would create a total air leak, which isn't correctable. Adding more air to the cuff without first removing residual air may cause cuff rupture. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 530.

A client is prescribed postural drainage because secretions are accumulating in the upper lobes of the lungs. The nurse instructs the client to: Lay in bed with the head on a pillow. Take prescribed albuterol (Ventolin) before performing postural drainage. Perform drainage 1 hour after meals. Hold each position for 5 minutes.

Take prescribed albuterol (Ventolin) before performing postural drainage. Explanation: When a client is to perform postural drainage, the nurse should instruct the client to use the prescribed bronchodilator (e.g., albuterol) first. This will open airways and promote drainage. The client is to perform postural drainage before meals, not after. This will aid in preventing nausea, vomiting, and aspiration. For secretions accumulated in the upper lobes, the client will sit up or even lean forward while sitting. Head on a pillow is not a sufficient increase in height. The client is also to lay in each position for 10 to 15 minutes. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 517.

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. Routine cuff deflation is recommended. Cuff pressures should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tube. 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.

The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient? The patient is hypoxic from suctioning. The patient is having a stress reaction. The patient is having a myocardial infarction. The patient is in a hypermetabolic state.

The patient is hypoxic from suctioning. Explanation: Apply suction while withdrawing and gently rotating the catheter 360 degrees (no longer than 10-15 seconds). Prolonged suctioning may result in hypoxia and dysrhythmias, leading to cardiac arrest. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 523.

A patient in the ICU has been orally intubated and on mechanical ventilation for 2 weeks after having a severe stroke. What action does the nurse anticipate the physician will take now that the patient has been intubated for this length of time? The patient will be extubated and another endotracheal tube will be inserted. The patient will be extubated and a nasotracheal tube will be inserted. The patient will have an insertion of a tracheostomy tube. The patient will begin the weaning process.

The patient will have an insertion of a tracheostomy tube. 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, to reduce the incidence of vocal cord paralysis (secondary to laryngeal nerve damage), and to decrease the work of breathing (Wiegand, 2011). Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 522.

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 aspiration Hypoxia Tracheal ischemia Tracheal bleeding Pressure necrosis

Tracheal ischemia Tracheal bleeding Pressure necrosis 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. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 522.

A client is being mechanically ventilated in the ICU. The ventilator alarms begin to sound. The nurse should complete which action first? Notify the respiratory therapist. Manually ventilate the client. Troubleshoot to identify the malfunction. Reposition the endotracheal tube.

Troubleshoot to identify the malfunction. Explanation: The nurse should first immediately attempt to identify and correct the problem; if the problem cannot be identified and/or corrected, the client must be manually ventilated with an Ambu bag. The respiratory therapist may be notified, but this is not the first action by the nurse. The nurse should not reposition the endotracheal tube as a first response to an alarm. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Respiratory Care Modalities, Chart 21-15, p. 534.

Which of the following are indicators that a client is ready to be weaned from a ventilator? Select all that apply. Vital capacity of 13 mL/kg Tidal volume of 8.5 mL/kg Rapid/shallow breathing index of 112 breaths/min PaO2 of 64 mm Hg FiO2 45%

Vital capacity of 13 mL/kg Tidal volume of 8.5 mL/kg PaO2 of 64 mm Hg Explanation: Weaning criteria for clients are as follows: Vital capacity 10 to 15 mL/kg; Maximum inspiratory pressure at least -20 cm H2; Tidal volume: 7 to 9 mL/kg; Minute ventilation: 6 L/min; Rapid/shallow breathing index below 100 breaths/min; PaO2 > 60 mm Hg; FiO2 < 40% Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 535.

Which type of ventilator has a preset volume of air to be delivered with each inspiration? Negative pressure Volume cycled Time cycled Pressure cycled

Volume cycled Explanation: With volume-cycled ventilation, the volume of air to be delivered with each inspiration is preset. Negative-pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a preset pressure, and then cycles off, and expiration occurs passively. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Respiratory Care Modalities, p. 526. Chapter 21: Respiratory Care Modalities - Page 526

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes? Water-seal chamber Air-leak chamber Collection chamber Suction control chamber

Water-seal chamber Explanation: Fluctuations in the water-seal compartment are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respirations. The air-leak meter — not chamber — detects air leaking from the pleural space. The collection chamber connects the chest tube from the client to the system. Drainage from the tube drains into and collects in a series of calibrated columns in this chamber. The suction control chamber provides the suction, which can be controlled to provide negative pressure to the chest. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 542.

Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. This therapy may be used for a client with: a compromised skin graft. a malignant tumor. pneumonia. hyperthermia.

a compromised skin graft. Explanation: A client with a compromised skin graft could benefit from hyperbaric oxygen therapy because increasing oxygenation at the wound site promotes wound healing. Hyperbaric oxygen therapy isn't indicated for malignant tumors, pneumonia, or hyperthermia. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 515.

A client with supraglottic cancer undergoes a partial laryngectomy. Postoperatively, a cuffed tracheostomy tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to: cough as the cuff is being deflated. take a deep breath as the nurse deflates the cuff. hold the breath as the cuff is being reinflated. exhale deeply as the nurse reinflates the cuff.

cough as the cuff is being deflated. Explanation: The nurse should instruct the client to cough during cuff deflation. If the client can't cough, the nurse should perform suctioning to prevent aspiration of secretions. Because the cuff should be deflated during expiration, the client shouldn't take a deep breath as the nurse deflates the cuff. Likewise, because the cuff is reinflated during inspiration, the client shouldn't hold the breath or exhale deeply during reinflation. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 536.

A nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is: helping him communicate. keeping his airway patent. encouraging him to perform activities of daily living (ADLs). preventing him from developing an infection.

keeping his airway patent. Explanation: Maintaining a patent airway is the most basic and critical human need. Helping the client communicate, encouraging him to perform ADLs, and preventing him from developing an infection are important to the client's well-being but not as important as having sufficient oxygen to breathe. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 531.

In general, chest drainage tubes are not used for a patient undergoing lobectomy. pneumonectomy. wedge resection. segmentectomy.

pneumonectomy. Explanation: Usually no drains are used for a client undergoing pneumonectomy because the accumulation of fluid in the empty hemothorax prevents mediastinal shift. With lobectomy, two chest tubes are usually inserted for drainage, the upper tube for air and the lower tube for fluid. With wedge resection, the pleural cavity usually is drained because of the possibility of an air or blood leak. With segmentectomy, drains are usually used because of the possibility of an air or blood leak. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Respiratory Care Modalities, Chart 21-17, p. 538.

A client who underwent thoracic surgery to remove a lung tumor had a chest tube placed anteriorly. The surgical team places this catheter to: remove air from the pleural space. remove fluid from the lungs. administer IV medication. ventilate the client.

remove air from the pleural space. Explanation: After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand. A catheter placed in the pleural space provides a drainage route through a closed or underwater-seal drainage system to remove air. Sometimes two chest catheters are placed following thoracic surgery: one anteriorly and one posteriorly. The anterior catheter removes air; the posterior catheter removes fluid. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Respiratory Care Modalities, p. 537.

The nurse is caring for a client who is scheduled for a lobectomy. Following the procedure, the nurse will plan care based on the client returning to the nursing unit with two chest tubes. returning from surgery with no drainage tubes. requiring mechanical ventilation following surgery. requiring sedation until the chest tube(s) are removed

returning to the nursing unit with two chest tubes. Explanation: The nurse should plan for the client to return to the nursing unit with two chest tubes intact. During a lobectomy, the lobe is removed, and the remaining lobes of the lung are re-expanded. Usually, two chest catheters are inserted for drainage. The upper tube is for air removal; the lower one is for fluid drainage. Sometimes only one catheter is needed. The chest tube is connected to a chest drainage apparatus for several days. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Respiratory Care Modalities, Chart 21-17, p. 538.

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: suctioning the tracheostomy tube frequently. using a cuffed tracheostomy tube. using the minimal-leak technique with cuff pressure less than 25 cm H2O. keeping the tracheostomy tube plugged.

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. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 524.

A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct? "Breathe in and out quickly." "You need to start using the incentive spirometer 2 days after surgery." "Before you do the exercise, I'll give you pain medication if you need it." "Don't use the incentive spirometer more than 5 times every hour."

"Before you do the exercise, I'll give you pain medication if you need it." Explanation: The nurse should assess the client's pain level before the client does incentive spirometry exercises and administer pain medication as needed. Doing so helps the client take deeper breaths and help prevents atelectasis. The client should breathe in slowly and steadily and hold the breath for 3 seconds after inhalation. The client should start doing incentive spirometry immediately after surgery and aim to do 10 incentive spirometry breaths every hour. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 516.

The nurse is preparing to perform chest physiotherapy (CPT) on a client. Which statement by the client tells the nurse that the procedure is contraindicated. "I just finished eating my lunch, I'm ready for my CPT now." "I just changed into my running suit; we can do my CPT now." "I received my pain medication 10 minutes ago, let's do my CPT now." "I have been coughing all morning and am barely bringing anything up."

"I just finished eating my lunch, I'm ready for my CPT now." Explanation: When performing CPT, the nurse ensures that the client is comfortable, is not wearing restrictive clothing, and has not just eaten. The nurse gives medication for pain, as prescribed, before percussion and vibration, splints any incision, and provides pillows for support, as needed. A goal of CPT is for the client to be able to mobilize secretions; the client who has an unproductive cough is a candidate for CPT. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Respiratory Care Modalities, p. 520.

A client has been placed on a ventilator, and the spouse begins to cry during the initial visit. What is the best therapeutic statement for the nurse to communicate? "The ventilator gives breaths every timed interval for breathing." "Tell me what you are feeling." "People on the ventilator do not feel pain." "I know this is stressful, but it is the best treatment."

"Tell me what you are feeling." Explanation: The best option is to have the spouse verbalize feelings. The other statements are not therapeutic because teaching should not be done while the spouse is crying. People on a ventilator may experience pain. The best treatment statement minimizes what the spouse is experiencing and does not encourage communication. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 532.

A client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. The client is placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. What setting would be the best maximum FIO2 setting? 0.21 0.35 0.5 0.7

0.5 Explanation: An FIO2 greater than 0.5 for as little as 16 to 24 hours can be toxic and can lead to decreased gas diffusion and surfactant activity. Clients with respiratory disorders are given oxygen therapy only to increase the partial pressure of oxygen (PaO2) back to the patient's normal baseline, which may vary from 60 to 95 mm Hg. In terms of the oxyhemoglobin dissociation curve, arterial hemoglobin at these levels is 80% to 98% saturated with oxygen; higher FiO2 flow values add no further significant amounts of oxygen to the red blood cells or plasma. Instead of helping, increased amounts of oxygen may produce toxic effects on the lungs and central nervous system or may depress ventilation. The ideal oxygen source is room air FIO2 0.21. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 512, 529.

The nurse is caring for a client in the ICU who required emergent endotracheal (ET) intubation with mechanical ventilation. The nurse receives an order to obtain arterial blood gases (ABGs) after the procedure. The nurse recognizes that ABGs should be obtained how long after mechanical ventilation is initiated? 10 minutes 15 minutes 20 minutes 25 minutes

20 minutes Explanation: The nurse records minute volume and obtains ABGs to measure carbon dioxide partial pressure (PaCO2), pH, and PaO2 after 20 minutes of continuous mechanical ventilation. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Respiratory Care Modalities, p. 536.

What range of pressure within the endotracheal tube cuff does the nurse maintain to prevent both injury and aspiration? 10 to 15 mm Hg 25 to 30 mm Hg 15 to 20 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Respiratory Care Modalities, Endotracheal Intubation, p. 521.

A client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for: 15 to 60 seconds. 5 to 20 minutes. 30 to 40 minutes. 45 to 60 minutes.

5 to 20 minutes. Explanation: Initially, the nurse should plug the opening in the tracheostomy tube for 5 to 20 minutes, then gradually lengthen this interval according to the client's respiratory status. A client who doesn't require continuous mechanical ventilation already is breathing without assistance, at least for short periods; therefore, plugging the opening of the tube for only 15 to 60 seconds wouldn't be long enough to reveal the client's true tolerance to the procedure. Plugging the opening for more than 20 minutes would increase the risk of acute respiratory distress because the client requires an adjustment period to start breathing normally. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 536.

The nurse is assigned to care for a client with a chest tube. The nurse should ensure that which item is kept at the client's bedside? An Ambu bag A bottle of sterile water An incentive spirometer A set of hemostats

A bottle of sterile water Explanation: It is essential that the nurse ensure that a bottle of sterile water is readily available at the client's bedside. If the chest tube and drainage system become disconnected, air can enter the pleural space, producing a pneumothorax. To prevent the development of a pneumothorax, a temporary water seal can be established by immersing the open end of the chest tube in a bottle of sterile water. There is no need to have an Ambu bag, incentive spirometer, or a set of hemostats at the bedside. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Respiratory Care Modalities, Quality and Safety Nursing Alert, p. 542.

A client with emphysema informs the nurse, "The surgeon will be removing about 30% of my lung so that I will not be so short of breath and will have an improved quality of life." What surgery does the nurse understand the surgeon will perform? A sleeve resection A lung volume reduction A wedge resection Lobectomy

A lung volume reduction Explanation: Lung volume reduction is a surgical procedure involving the removal of 20%-30% of a client's lung through a midsternal incision or video thoracoscopy. The diseased lung tissue is identified on a lung perfusion scan. This surgery leads to significant improvements in dyspnea, exercise capacity, quality of life, and survival of a subgroup of people with end-stage emphysema. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 538.

A client with chronic lung disease is prescribed chest percussion. For which reason will the nurse question this treatment for the client? Age 75 years Left hip replaced 5 years ago Receiving intravenous fluid therapy Diagnosed with bacterial pneumonia

Age 75 years Explanation: Chest percussion is used to help dislodge mucus adhering to the bronchioles and bronchi. It is carried out by cupping the hands and lightly striking the chest wall in a rhythmic fashion over the lung segment to be drained. The wrists are alternately flexed and extended so that the chest is cupped or clapped in a painless manner. Percussion is performed for 3 to 5 minutes for each position while the client uses diaphragmatic breathing. As a precaution, percussion over chest drainage tubes and the sternum, spine, liver, kidneys, spleen, or breasts (in women) is avoided. Percussion is performed cautiously in older adult clients because of the increased incidence of osteoporosis and risk of rib fracture. Percussion is not contraindicated after hip replacement surgery. It is not contraindicated while receiving intravenous fluid therapy. It would be an appropriate treatment for a client with bacterial pneumonia.

The nurse is caring for a client following a wedge resection. While the nurse is assessing the client's chest tube drainage system, constant bubbling is noted in the water seal chamber. This finding indicates which problem? Air leak Tidaling Tension pneumothorax Increased drainage

Air leak Explanation: The nurse needs to observe for air leaks in the drainage system; they are indicated by constant bubbling in the water seal chamber, or by the air leak indicator in dry systems with a one-way valve. Tidaling is fluctuation of the water level in the water seal that shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Respiratory Care Modalities, p. 542.

A patient is brought into the emergency department with carbon monoxide poisoning after escaping a house fire. What should the nurse monitor this patient for? Anemic hypoxia Histotoxic hypoxia Hypoxic hypoxia Stagnant hypoxia

Anemic hypoxia Explanation: Anemic hypoxia is a result of decreased effective hemoglobin concentration, which causes a decrease in the oxygen-carrying capacity of the blood. It is rarely accompanied by hypoxemia. Carbon monoxide poisoning, because it reduces the oxygen-carrying capacity of hemoglobin, produces similar effects but is not strictly anemic hypoxia, because hemoglobin levels may be normal. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 511.

A client has a sucking stab wound to the chest. Which action should the nurse take first? Draw blood for a hematocrit and hemoglobin level. Apply a dressing over the wound and tape it on three sides. Prepare a chest tube insertion tray. Prepare to start an I.V. line.

Apply a dressing over the wound and tape it on three sides. Explanation: The nurse should immediately apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 540.

A client on long-term mechanical ventilation becomes very frustrated when he tries to communicate. Which intervention should the nurse perform to assist the client? Assure the client that everything will be all right and that he shouldn't become upset. Ask a family member to interpret what the client is trying to communicate. Ask the physician to wean the client off the mechanical ventilator to allow the client to talk. Ask the client to write, use a picture board, or spell words with an alphabet board.

Ask the client to write, use a picture board, or spell words with an alphabet board. Explanation: If the client uses an alternative method of communication, such as writing, using a picture board, or spelling words on an alphabet board, he'll feel more in control and be less frustrated. Assuring the client that everything will be all right offers false reassurance and telling him not to be upset minimizes his feelings. Neither of these methods helps the client to communicate. Family members are also likely to encounter difficulty interpreting the wishes of a client with an endotracheal tube or tracheostomy tube. Making them responsible for interpreting the client's gestures may frustrate them. The client may be weaned off a mechanical ventilator only when the physiologic parameters for weaning have been met. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 534.

A client in the intensive care unit has a tracheostomy with humidified oxygen being instilled through it. The client is expectorating thick yellow mucus through the tracheostomy tube frequently. The nurse Sets a schedule to suction the tracheostomy every hour Assesses the client's tracheostomy and lung sounds every 15 minutes Decreases the amount of humidity set to flow through the tracheostomy tube Encourages the client to cough every 30 minutes and prn

Assesses the client's tracheostomy and lung sounds every 15 minutes Explanation: Tracheal suctioning is performed when secretions are obvious or adventitious breath sounds are heard. The client is producing thick yellow mucus frequently, so the nurse needs to make frequent assessments about the need for suctioning. Suctioning every hour could be too frequent or not frequent enough. It also does not address the client's needs. The client needs high humidity to liquify the mucus, which is described as thick. The client has a decreased effectiveness of coughing with a tracheostomy tube. Again, this is not a viable option. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 544.

A nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority? Posting a "No smoking" sign over the client's bed Applying an oil-based lubricant to the client's mouth and nose Assessing the client's respiratory status, orientation, and skin color Changing the mask and tubing daily

Assessing the client's respiratory status, orientation, and skin color Explanation: A nonrebreather mask can deliver high concentrations of oxygen to the client in acute respiratory distress. Assessment of a client's status is a priority for determining the effectiveness of therapy. There is no need for the nurse to post a "No smoking" sign over the client's bed. Smoking is a fire hazard and is prohibited in hospitals regardless of whether the client is receiving oxygen from a nonrebreather mask. Oil-based lubricants can cause pneumonia by promoting bacteria growth. Equipment should be changed daily, but this is a lower priority than assessing respiratory status, orientation, and skin color. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 514.

Which ventilator mode provides full ventilatory support by delivering a present tidal volume and respiratory rate? IMV SIMV Assist control Pressure support

Assist control Explanation: Assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate. IMV provides a combination of mechanically assisted breaths and spontaneous breaths. SIMV delivers a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the patient can breathe spontaneously with no assistance from the ventilator for those extra breaths. Pressure support ventilation assists SIMV by applying a pressure plateau to the airway throughout the client-triggered inspiration to decrease resistance within the tracheal tube and ventilator tubing. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Respiratory Care Modalities, p. 527.

An adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Ordered respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure? Immediately before a meal At bedtime When bronchospasms occur When secretions have mobilized

At bedtime Explanation: The nurse should perform chest physiotherapy at bedtime to reduce secretions in the client's lungs during the night. Performing it immediately before a meal may tire the client and impair the ability to eat. Percussion and vibration, components of chest physiotherapy, may worsen bronchospasms; therefore, the procedure is contraindicated in clients with bronchospasms. Secretions that have mobilized (especially when suction equipment isn't available) are a contraindication for postural drainage, another component of chest physiotherapy. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 517.

A client who is intubated for mechanical ventilation has met the criteria for weaning. Which additional assessment findings indicate to the nurse that the client is eligible for a T-piece? Select all that apply. Awake and alert Gag reflex intact Cough reflex intact Suctioned every 2 hours Breathing without difficulty

Awake and alert Gag reflex intact Cough reflex intact Breathing without difficulty Explanation: Respiratory weaning, the process of withdrawing the client from dependence on the ventilator, occurs in stages. Weaning from mechanical ventilation is performed at the earliest possible time according to client safety. Weaning is started when the client is physiologically and hemodynamically stable, demonstrates spontaneous breathing capability, is recovering from the acute stage of medical and surgical problems, and when the cause of respiratory failure is sufficiently reversed. Weaning through the use of a T-piece is conducted by disconnecting the client from the ventilator so that the client performs all the work of breathing. This method of weaning is used when the client is awake and alert, has intact gag and cough reflexes, and is breathing without difficulty. The frequency of suctioning is not among the criteria used to determine if a client is eligible for weaning with a T-piece.

A nurse is working with a client being extubated from the ventilator. Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain? Fluid intake for the past 24 hours Baseline arterial blood gas (ABG) levels Complete blood count results Electrocardiogram (ECG) results

Baseline arterial blood gas (ABG) levels Explanation: Before weaning the client from mechanical ventilation, it's most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Anemic hypoxia is an issue, but would not be most important factor before weaning ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 21: Respiratory Care Modalities, p. 528.

Which is an adverse reaction that would require the process of weaning from a ventilator to be terminated? Blood pressure increase of 20 mm Hg PaO2 60 mmHg with an FiO2 <40% Heart rate <100 bpm Vital capacity of 12 mL/kg

Blood pressure increase of 20 mm Hg Explanation: Criteria for terminating the weaning process include heart rate increase of 20 beats/min and systolic blood pressure increase of 20 mm Hg. A normal vital capacity is 10 to 15 mL/kg. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 21: Respiratory Care Modalities, Chart 21-16, p. 535.