Chapter 21: Respiratory Care Modalities PrepU
The nurse is educating a patient with COPD about the technique for performing pursed-lip breathing. What does the nurse inform the patient is the importance of using this technique? a) It prolongs exhalation. b) It increases the respiratory rate to improve oxygenation. c) It will assist with widening the airway. d) It will prevent the alveoli from overexpanding.
a) It prolongs exhalation. The goal of pursed-lip breathing is to prolong exhalation and increase airway pressure during expiration, thus reducing the amount of trapped air and the amount of airway resistance.
Which is a potential complication of a low pressure in the endotracheal tube cuff? a) Tracheal bleeding b) Aspiration pneumonia c)Tracheal ischemia d) Pressure necrosis
b) Aspiration pneumonia Low pressure in the cuff can increase the risk for aspiration pneumonia. High pressure in the cuff can cause tracheal bleeding, ischemia, and pressure necrosis.
The nurse is preparing to assist the health care provider to remove a client's chest tube. Which instruction will the nurse correctly give to the client? a) "When the tube is being removed, take a deep breath" b) "Exhale forcefully while the chest tube is being removed." c) "While the chest tube is being removed, raise your arms above your head." d) "Do not move during the removal of the chest tube because moving will make it more painful."
a) "When the tube is being removed, take a deep breath" When assisting in the removal of a chest tube, instruct the client to take a deep breath or to breathe quietly. The chest tube is then clamped and quickly removed. Simultaneously, a small bandage is applied and made airtight with petrolatum gauze covered by a 4 × 4-inch gauze pad and thoroughly covered and sealed with nonporous tape. The other options are incorrect instructions for the client.
For a client with an endotracheal (ET) tube, which nursing action is the most important? a) Auscultating the lungs for bilateral breath sounds b) Turning the client from side to side every 2 hours c) Monitoring serial blood gas values every 4 hours d) Providing frequent oral hygiene
a) Auscultating the lungs for bilateral breath sounds For the client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although turning the client from side to side every 2 hours, monitoring serial blood gas values every 4 hours, and providing frequent oral hygiene are appropriate actions for this client, they're secondary to ensuring adequate oxygenation.
The nurse is caring for a client following a thoracotomy. Which finding requires immediate intervention by the nurse? a) Chest tube drainage, 190 mL/hr b) Moderate amounts of colorless sputum c) Heart rate, 112 bpm d) Pain of 5 on a 1-to-10 scale
a) Chest tube drainage, 190 mL/hr 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.
Which oxygen administration device has the advantage of providing a high oxygen concentration? a) Nonrebreathing mask B) Venturi mask c) Catheter d) Face tent
a) Nonrebreathing mask The nonrebreathing mask provides high oxygen concentration, but it usually fits poorly. However, if the nonrebreathing mask fits the client snugly and both side exhalation ports have one-way valves, it is possible for the client to receive 100% oxygen, making the nonrebreathing mask a high-flow oxygen system. The Venturi mask provides low levels of supplemental oxygen. The 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.
The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia? a) PaO2 b) pH c) PCO2 d) HCO3
a) PaO2 Hypoxemic hypoxia, or hypoxemia, is a decreased oxygen level in the blood (PaO2) resulting in decreased oxygen diffusion into the tissues.
A nurse is caring for a client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do? a) Place the end of the chest tube in a container of sterile saline. b) Clamp the chest tube immediately. c) Secure the chest tube with tape. d) Apply an occlusive dressing and notify the physician.
a) Place the end of the chest tube in a container of sterile saline. If a chest drainage system is disconnected, the nurse may place the end of the chest tube in a container of sterile saline or water to prevent air from entering the chest tube, thereby preventing negative respiratory pressure. The nurse should apply an occlusive dressing if the chest tube is pulled out — not if the system is disconnected. The nurse shouldn't clamp the chest tube because clamping increases the risk of tension pneumothorax. The nurse should tape the chest tube securely to prevent it from being disconnected, rather than taping it after it has been disconnected.
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? a) The patient is hypoxic from suctioning. b) The patient is having a stress reaction. c) The patient is having a myocardial infarction. d) The patient is in a hypermetabolic state.
a) The patient is hypoxic from suctioning. 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.
A client who must begin oxygen therapy asks the nurse why this treatment is necessary? What would the nurse identify as the goals of oxygen therapy? Select all that apply. a) To decrease the work of breathing b) To clear respiratory secretions c) To reduce stress on the myocardium d) To provide adequate transport of oxygen in the blood e) To provide visual feedback to encourage the client to inhale slowly and deeply
a) To decrease the work of breathing c) To reduce stress on the myocardium d) To provide adequate transport of oxygen in the blood Oxygen therapy is designed to provide adequate transport of oxygen in the blood while decreasing the work of breathing and reducing stress on the myocardium. Incentive spirometry is a respiratory modality that provides visual feedback to encourage the client to inhale slowly and deeply to maximize lung inflation and prevent or reduce atelectasis. A mini-nebulizer is used to help clear secretions.
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) a compromised skin graft. b) a malignant tumor. c) pneumonia. d) hyperthermia.
a) a compromised skin graft. 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.
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: a) 15 to 60 seconds. b) 5 to 20 minutes. c) 30 to 40 minutes. d) 45 to 60 minutes.
b) 5 to 20 minutes. 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.
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) A sleeve resection b) A lung volume reduction c) A wedge resection d) Lobectomy
b) A lung volume reduction 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.
The nurse received a client from the post-anesthesia care unit (PACU) who has a chest tube to a closed drainage system. Report from the PACU nurse included drainage in the chest tube at 80 mL of bloody fluid. Fifteen minutes after transfer from the PACU, the chest tube indicates drainage as pictured. The client is reporting pain at "8" on a scale of 0 to 10. The first action of the nurse is to: a) Notify the physician. b) Assess pulse and blood pressure. c) Administer prescribed pain medication. d) Lay the client's head to a flat position.
b) Assess pulse and blood pressure. The client has bled 120 mL of bloody drainage in the chest drainage system within 15 minutes. It is most important for the nurse to assess for signs and symptoms of hemorrhage, which may be indicated by a rapid pulse and decreasing blood pressure. The nurse may then lay the client in a flat position and notify the physician.
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? a) Immediately before a meal b) At bedtime c) When bronchospasms occur d) When secretions have mobilized
b) At bedtime 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.
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? a) Simple mask b) Nonrebreather mask c) Face tent d) Nasal cannula
b) Nonrebreather mask 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.
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? a) Check for an apical pulse. b) Suction the client's artificial airway. c) Increase the oxygen percentage. d) Ventilate the client with a handheld mechanical ventilator.
b) Suction the client's artificial airway. A high-pressure alarm on a continuous mechanical ventilator indicates an obstruction in the flow of gas from the machine to the client. The nurse should suction the client's artificial airway to remove respiratory secretions that could be causing the obstruction. The sounding of a ventilator alarm has no relationship to the apical pulse. Increasing the oxygen percentage and ventilating with a handheld mechanical ventilator wouldn't correct the airflow blockage.
A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? a) The client has a pneumothorax. b) The system has an air leak. c) The system is functioning normally. d) The chest tube is obstructed.
b) The system has an air leak. Constant bubbling in the water-seal chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the fluid would stop fluctuating in the water-seal chamber.
Which is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means? a) Nasal cannula b) Venturi mask c) T-piece d) Partial-rebreathing mask
b) Venturi mask The Venturi mask is the most reliable and accurate method for delivering a precise concentration of oxygen through noninvasive means. The mask is constructed in a way that allows a constant flow of room air blended with a fixed flow of oxygen. Nasal cannula, T-piece, and partial-rebreathing masks are not the most reliable and accurate methods of oxygen administration.
Which type of ventilator has a preset volume of air to be delivered with each inspiration? a) Negative pressure b) Volume cycled c) Time cycled d) Pressure cycled
b) Volume cycled 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.
Which type of ventilator has a preset volume of air to be delivered with each inspiration? a) Negative-pressure b) Volume-controlled c) Time-cycled d) Pressure-cycled
b) Volume-controlled With volume-controlled 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.
A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct? a) "Breathe in and out quickly." b) "You need to start using the incentive spirometer 2 days after surgery." c) "Before you do the exercise, I'll give you pain medication if you need it." d) "Don't use the incentive spirometer more than 5 times every hour."
c) "Before you do the exercise, I'll give you pain medication if you need it." 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.
A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for a) Higher than normal endotracheal cuff pressure b) A cut or slice in the tubing from the ventilator c) A kink in the ventilator tubing d) Malfunction of the alarm button
c) A kink in the ventilator tubing One event that could cause the ventilator's peak-airway-pressure alarm to sound is a kink in the ventilator tubing. After making this and other assessments without correction, then it could be a malfunction of the alarm button. Higher than normal endotracheal cuff pressure could cause client tissue damage but would not make the ventilator alarms sound. A cut or slice in the tubing from the ventilator would result in decreased pressure.
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? a) Trauma b) Infection c) Cancer d) Emphysema
c) Cancer 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.
A client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this client? a) Surgery to remove the tonsils and adenoids b) Medications to assist the patient with sleep at night c) Continuous positive airway pressure (CPAP) d) Bi-level positive airway pressure (BiPAP)
c) Continuous positive airway pressure (CPAP) 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.
After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must: a) report fluctuations in the water-seal chamber. b) clamp the chest tube once every shift. c) encourage coughing and deep breathing. d) milk the chest tube every 2 hours.
c) encourage coughing and deep breathing. When caring for a client who's recovering from a thoracotomy, the nurse should encourage coughing and deep breathing to prevent pneumonia. Fluctuations in the water-seal chamber are normal. Clamping the chest tube could cause a tension pneumothorax. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage.
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? a) Call respiratory therapy and wait until they arrive to determine what is happening. b) Stop the ventilator by pressing the off button, wait 15 seconds, and then turn it on again to see if the alarm stops. c) Suction the patient since the patient may be obstructed by secretions. d) Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved.
d) Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved. 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.
Which of the following are indicators that a client is ready to be weaned from a ventilator? Select all that apply. 1) Vital capacity of 13 mL/kg 2) Tidal volume of 8.5 mL/kg 3) Rapid/shallow breathing index of 112 breaths/min 4) PaO2 of 64 mm Hg 5) FiO2 45%
1) Vital capacity of 13 mL/kg 2) Tidal volume of 8.5 mL/kg 4) PaO2 of 64 mm Hg 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%
A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? a) Endotracheal suctioning b) Encouragement of coughing c) Use of a cooling blanket d) Incentive spirometry
a) Endotracheal suctioning Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.
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? a) Measuring and documenting the drainage in the collection chamber b) Maintaining continuous bubbling in the water-seal chamber c) Keeping the collection chamber at chest level d) Stripping the chest tube every hour
a) Measuring and documenting the drainage in the collection chamber 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.
The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for: a) Symmetry of the client's chest expansion b) Tracheal cuff pressure set at 30 mm Hg c) Cool air humidified through the tube d) A scheduled time for deflation of the tracheal cuff
a) Symmetry of the client's chest expansion Immediately after intubation, the nurse should check for symmetry of chest expansion. This is one finding that indicates successful endotracheal placement. The tracheal cuff pressure is set between 15 and 20 mm Hg. Routine deflation of the tracheal cuff is not recommended, because the client could then aspirate secretions during the period of deflation. Warm, high, humidified air is administered through the endotracheal tube.
A client has a sucking stab wound to the chest. Which action should the nurse take first? a) Draw blood for a hematocrit and hemoglobin level. b) Apply a dressing over the wound and tape it on three sides. c) Prepare a chest tube insertion tray. d) Prepare to start an I.V. line.
b) Apply a dressing over the wound and tape it on three sides. 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.
A client has a sucking stab wound to the chest. Which action should the nurse take first? a) Prepare to start an I.V. line. b) Apply a dressing over the wound and tape it on three sides. c) Draw blood for a hematocrit and hemoglobin level. d) Prepare a chest tube insertion tray.
b) Apply a dressing over the wound and tape it on three sides. 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.
Which is a potential complication of a low pressure in the endotracheal tube cuff? a) Tracheal bleeding b) Aspiration pneumonia c) Tracheal ischemia d) Pressure necrosis
b) Aspiration pneumonia Low pressure in the cuff can increase the risk for aspiration pneumonia. High pressure in the cuff can cause tracheal bleeding, ischemia, and pressure necrosis.
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? a) Anemic hypoxia b) Circulatory hypoxia c) Histotoxic hypoxia d) Hypoxemic hypoxia
b) Circulatory hypoxia 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 nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result? a) Promote more efficient and controlled ventilation and to decrease the work of breathing b) Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing c) Promote the strengthening of the client's diaphragm d) Promote the client's ability to take in oxygen
b) Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing Pursed-lip breathing, which improves oxygen transport, helps induce a slow, deep breathing pattern and assists the client to control breathing, even during periods of stress. This type of breathing helps prevent airway collapse secondary to loss of lung elasticity in emphysema.
Which oxygen administration device has the advantage of providing a high oxygen concentration? a) Venturi mask b) Nonrebreathing mask c) Face tent d) Catheter
b) Nonrebreathing mask The nonrebreathing mask provides high oxygen concentration, but it usually fits poorly. However, if the nonrebreathing mask fits the client snugly and both side exhalation ports have one-way valves, it is possible for the client to receive 100% oxygen, making the nonrebreathing mask a high-flow oxygen system. The Venturi mask provides low levels of supplemental oxygen. The 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.
A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse a) Consults with the physician about removing the client from the ventilator b) Changes the setting on the ventilator to increase breaths to 14 per minute c) Continues assessing the client's respiratory status frequently d) Contacts the respiratory therapy department to report the ventilator is malfunctioning
c) Continues assessing the client's respiratory status frequently The SIMV setting on a ventilator allows the client to breathe spontaneously with no assistance from the ventilator for those extra breaths. Data in the stem suggest that the ventilator is working correctly. The nurse would continue making frequent respiratory assessments of the client. There are not sufficient data to suggest the client could be removed from the ventilator. There is no reason to increase the ventilator's setting to 14 breaths per minute or to contact respiratory therapy to report the machine is not working properly.
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? a) pH b) Bicarbonate (HCO3-) c) Partial pressure of arterial oxygen (PaO2) d) Partial pressure of arterial carbon dioxide (PaCO2)
c) Partial pressure of arterial oxygen (PaO2) The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3-, and PaCO2
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? a) pH b) Bicarbonate (HCO3-) c) Partial pressure of arterial oxygen (PaO2) d) Partial pressure of arterial carbon dioxide (PaCO2)
c) Partial pressure of arterial oxygen (PaO2) The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3-, and PaCO2
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? a) Immediately reconnect the chest tube to the drainage apparatus. b) Clamp the chest tube close to the connection site. c) Place the chest tube in sterile water. d) Notify the health care provider.
c) Place the chest tube in sterile water. 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.
A nurse is weaning a client from mechanical ventilation. Which nursing assessment finding indicates the weaning process should be stopped? a) Respiratory rate of 16 breaths/minute b) Oxygen saturation of 93% c) Runs of ventricular tachycardia d) Blood pressure remains stable
c) Runs of ventricular tachycardia 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.
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 a) requiring sedation until the chest tube(s) are removed. b) returning from surgery with no drainage tubes. c) returning to the nursing unit with two chest tubes. d) requiring mechanical ventilation following surgery.
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.
A nurse is caring for a client with COPD who needs teaching on pursed-lip breathing. Place the steps in order in which the nurse will instruct the client. a) "Slowly count to 7." b) "Inhale through your nose." c) "Slowly count to 3." d) "Exhale slowly through pursed lips."
b) "Inhale through your nose." c) "Slowly count to 3." d) "Exhale slowly through pursed lips." a) "Slowly count to 7." Pursed-lip breathing is a technique used to prolong exhalation by propping the airways open and promoting the removal of trapped air and carbon dioxide. The nurse should instruct the client to first inhale through the nose to a slow count of 3. Next, the client should exhale slowly through pursed lips for a count of 7.
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? a) "The ventilator gives breaths every timed interval for breathing." b) "Tell me what you are feeling." c) "People on the ventilator do not feel pain." d) "I know this is stressful, but it is the best treatment."
b) "Tell me what you are feeling." 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.
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? a) "The ventilator gives breaths every timed interval for breathing." b) "Tell me what you are feeling." c) "People on the ventilator do not feel pain." d) "I know this is stressful, but it is the best treatment."
b) "Tell me what you are feeling." 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.
A nurse is caring for a client who was intubated because of respiratory failure. The client is now receiving mechanical ventilation with a preset tidal volume and number of breaths each minute. The client has the ability to breathe spontaneously between the ventilator breaths with no ventilator assistance. The nurse should document the ventilator setting as: a) pressure support ventilation (PSV). b) synchronized intermittent mandatory ventilation (SIMV). c) assist-control (AC) ventilation. d) continuous positive airway pressure (CPAP).
b) synchronized intermittent mandatory ventilation (SIMV). In SIMV mode, the ventilator delivers a preset number of breaths at a preset tidal volume. The client can breathe on his own in between the breaths delivered by the ventilator. In PSV, a pressure plateau is added to the ventilator to prevent the airway pressure from falling beneath a preset level. In AC ventilation, the ventilator delivers a preset number of breaths at a preset tidal volume and any breaths that the client takes on his own are assisted by the ventilator so they reach the preset tidal volume. In CPAP, the ventilator provides only positive airway pressure; it doesn't provide any breaths to the client.
A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings? a) 45 mm Hg b) 58 mm Hg c) 84 mm Hg d) 120 mm Hg
c) 84 mm Hg In general, clients with respiratory conditions are given oxygen therapy only to increase the arterial oxygen pressure (PaO2) back to the client's normal baseline, which may vary from 60 to 95 mm Hg.
