Med Surg II - Chapter 28 - Care of Patients Requiring Oxygen Therapy or Tracheostomy

A patient who has thick, sticky respiratory secretions requires high-flow, humidified oxygen delivery. Which oxygen delivery equipment does the nurse use for this patient? 1 Face tent 2 Venturi mask 3 Aerosol mask 4 Nonrebreather mask

3 Aerosol mask An aerosol mask is used when high humidity is needed, as with thick secretions. A face tent is used for patients with burns or facial trauma. A nonrebreather mask is a low-flow oxygen delivery system. The Venturi mask is not the best method to deliver high-humidity oxygen.

The nurse is teaching a patient with a tracheostomy who is to be discharged about home tracheostomy management. Which statement by the patient indicates that further instruction may be needed? 1 "I should sleep in a room with a dehumidifier." 2 "I should not lie down within 30 minutes after eating." 3 "If I notice white spots in my mouth, I should call my provider." 4 "I will change the tracheostomy holder at least once daily."

1 "I should sleep in a room with a dehumidifier." Patients with tracheostomies should be taught to humidify (not dehumidify) homes to prevent drying of secretions. White spots may indicate Candida infection and should be reported. Patients should be upright to at least 30 degrees after eating to prevent aspiration. The tape ties or Velcro holder should be changed once daily and as needed if it becomes soiled.

Which of these are valuable instructions for the nurse regarding best practices for patient safety during oxygen therapy? Select all that apply. 1 "Position the tubing so it does not pull on the patient's face or the artificial airway." 2 "Mouth care should be infrequent to prevent irritation to the nasal cannula." 3 "The presence of smoking, lit matches, or candles in the immediate area is considered safe." 4 "Lubrication of the patient's nostrils, face, and lips is essential to prevent drying." 5 "Ensure that the oxygen and humidification equipment are functioning properly."

1 "Position the tubing so it does not pull on the patient's face or the artificial airway." 4 "Lubrication of the patient's nostrils, face, and lips is essential to prevent drying." 5 "Ensure that the oxygen and humidification equipment are functioning properly." During oxygen therapy, lubrication of the patient's nostrils, face, and lips with nonpetroleum cream is essential to relieve the drying effects of oxygen. For effective oxygen therapy, the oxygen and humidification equipment should be functioning properly. The tubing should be positioned in such a way that it does not pull on the patient's face or artificial airway. Mouth care is an integral part of caring for a patient who is undergoing oxygen therapy and should be provided every 8 hours or as needed. Care should be taken that smoking, lit matches, and candles are not present in the immediate vicinity of the oxygen therapy room or area because oxygen is combustible.

The normal balance of the body's oxygen intake and delivery system can be altered by nonrespiratory conditions including fever, sepsis, heart failure, poisoning, and poor hemoglobin quality. Which possible situations may result? Select all that apply. 1 Decreased cardiac output 2 Increased oxygen demand by the body 3 Decreased oxygen-carrying capability of the blood 4 Major infections entering the patient's bloodstream 5 Decreased effectiveness of oxygen utilization by the body

1 Decreased cardiac output 2 Increased oxygen demand by the body 3 Decreased oxygen-carrying capability of the blood Conditions such as fever, sepsis, heart failure, poisoning, and poor hemoglobin quality alter the body's oxygen and delivery system balance by increasing oxygen demand, decreasing cardiac output, and decreasing the oxygen-carrying capacity of the blood. These conditions typically do not decrease the utilization of the oxygen in the body. The entry of organisms into the bloodstream is related to barrier breakdown.

Which nursing interventions are appropriate to prevent hypoxia in the patient with tracheostomy? Select all that apply. 1 Monitoring the heart rate 2 Monitoring the temperature 3 Monitoring the respiratory rate 4 Hyperoxygenating the patient with 100% oxygen 5 Having the patient take deep breaths before suctioning

1 Monitoring the heart rate 4 Hyperoxygenating the patient with 100% oxygen 5 Having the patient take deep breaths before suctioning The nurse monitors the heart rate of the patient to assess the patient's tolerance to tracheostomy. One of the preventive interventions for hypoxia is hyperoxygenating the patient with 100% oxygen using a manual resuscitation bag attached to an oxygen source. Instructing the patient to take deep breaths three or four times before suctioning with the existing oxygen delivery system may also prove to be helpful. Monitoring the temperature and respiratory rate are not relevant to preventing hypoxia.

Which value indicates clinical hypoxemia and the need to increase oxygen delivery? 1 PaO 2 of 65 mm Hg 2 PaCO 2 of 30 mm Hg 3 Hemoglobin of 22 g/dL 4 Oxygen saturation of 88%

1 PaO 2 of 65 mm Hg A PaO 2 of 65 mm Hg indicates low levels of oxygen in the arterial blood; this is considered hypoxemia. Hemoglobin measures oxygen-carrying capacity. PaCO 2 of 30 mm Hg indicates low carbon dioxide levels in the blood. Oxygen saturation measures tissue perfusion.

What are typical postoperative concerns after a new tracheostomy? Select all that apply. 1 Tube obstruction 2 Tube dislodgement 3 Accidental decannulation 4 Securing the endotracheal tube 5 Plugging the tube for communication

1 Tube obstruction 2 Tube dislodgement 3 Accidental decannulation Maintaining patency of the airway is a primary concern after a new tracheostomy. Tube obstruction, dislodgement, or decannulation can cause an airway emergency. Plugging the tube for communication will not be a priority in the immediate postoperative period. Communication should rely on nonverbal techniques such as sign boards, etc. This patient would most likely not have an endotracheal tube.

The primary health care provider has written an order to resume the diet for a patient with a tracheostomy following a laryngectomy. What does the nurse include when teaching the patient about prevention of aspiration? 1 Raise the head of the bed 30 degrees when eating. 2 All liquids will need to be thickened, including water. 3 When swallowing, raise the chin as though looking at the ceiling. 4 If not already inflated, inflate the tube cuff when eating or drinking.

2 All liquids will need to be thickened, including water. Thickening all liquids gives the patient more control over aspiration when swallowing. The patient should be sitting upright when eating and should tuck the chin down and lower the forehead while swallowing to prevent aspiration. Due to the close proximity of the cuffed tube to the esophagus, it may interfere with the passage of food; the cuff should therefore be deflated to facilitate swallowing and prevent aspiration.

Which nursing interventions should the nurse follow when providing low-flow oxygen to a patient through a nasal cannula? Select all that apply. 1 Provide emotional support 2 Assess the patency of the nostrils 3 Ensure secure fitting of the prongs 4 Applying water-soluble jelly to nares 5 Monitor the blood pressure regularly

2 Assess the patency of the nostrils 3 Ensure secure fitting of the prongs 4 Applying water-soluble jelly to nares An assessment for the patency of the nostrils is important because congestion or a deviated septum prevents effective delivery of oxygen through the nares. A poorly fitting nasal cannula leads to hypoxemia and skin breakdown. Application of water-soluble jelly on the nares should be done as needed, or when necessary. This jelly prevents mucosal irritation related to the drying effect of oxygen and promotes comfort. It is more important for the nurse to provide emotional support for a patient wearing a face mask than to a patient using a nasal cannula. Monitoring the patient's blood pressure regularly may not help as a nursing intervention.

Which factors should be considered when determining which type of oxygen a patient will require for home oxygen therapy? Select all that apply. 1 There are young children living in the home with the patient. 2 Liquid oxygen is available in lightweight, easy-to-carry containers. 3 There are smokers in the family living in the house with the patient. 4 An oxygen concentrator is noisy and big and requires refilling for use. 5 Liquid oxygen tanks last longer than equal-sized gaseous oxygen tanks.

2 Liquid oxygen is available in lightweight, easy-to-carry containers. 5 Liquid oxygen tanks last longer than equal-sized gaseous oxygen tanks. Liquid oxygen can be placed in multiple sizes of containers based on ease and need for portability. Compared to gaseous oxygen in the same size container, liquid oxygen will last longer. Although the oxygen concentrator is large and can be noisy, it doesn't require refilling for use. All people living with the patient must be cautioned about open flames in the home, but a family member who smokes should not preclude a patient's access to home oxygen. Oxygen in the home will not harm children if proper precautions are taken.

A patient with respiratory failure has been intubated and placed on a ventilator and is requiring 100% oxygen delivery to maintain adequate oxygenation. Twenty-four hours later, the nurse notes new-onset crackles and decreased breath sounds, and the most recent arterial blood gases (ABGs) show a PaO 2 level of 95 mm Hg. The ventilator is not set to provide positive end-expiratory pressure (PEEP). Why is the nurse concerned? 1 The low PaO 2 level may result in oxygen toxicity. 2 Lung sounds may indicate absorption atelectasis. 3 The level of oxygen delivery may indicate absorption atelectasis. 4 The 100% oxygen delivery requirement indicates immediate extubation.

2 Lung sounds may indicate absorption atelectasis. High levels of oxygen delivery can result in collapsed alveoli and absorption atelectasis. PEEP can help alveoli remain properly inflated. High PaO 2 levels may result in oxygen toxicity. The need for 100% oxygen delivery does not suggest that the patient should be extubated; rather, it suggests that the patient continues to require intubation and mechanical ventilation. Although high levels of oxygen delivery can result in absorption atelectasis, this is not an indicator; rather, it is a cause.

Which principle should guide the nurse's decision regarding oral care for a patient with a tracheostomy during the first 24 hours postoperative? 1 High protein intake is indicated to promote optimal healing. 2 Oral care is indicated to decrease the accumulation of organisms. 3 If the patient is not taking oral nutrition, it is not a concern at this time. 4 Oral care is not indicated if the patient is being suctioned on a regular basis.

2 Oral care is indicated to decrease the accumulation of organisms. Oral care helps decrease the accumulation of organisms present in the mouth that can contribute to pneumonia and should be a regular part of postoperative care. Good oral care is important even if the patient is not eating, which actually serves to facilitate cleansing of the oral cavity. Protein will aid healing but does not negate the need for oral care.

A patient with sleep apnea has a new prescription for a BiPAP device to be worn at night. What does the nurse include in the teaching for this assistive device? Select all that apply. 1 The BiPAP device only delivers room air. 2 The mask must fit tightly to form a proper seal. 3 BiPAP provides the same pressure during inhalation and exhalation. 4 BiPAP provides positive pressure during inhalation and exhalation to keep alveoli open. 5 BiPAP improves airflow during sleep and promotes comfort by reducing dyspnea.

2 The mask must fit tightly to form a proper seal. 4 BiPAP provides positive pressure during inhalation and exhalation to keep alveoli open. 5 BiPAP improves airflow during sleep and promotes comfort by reducing dyspnea. To ensure delivery of prescribed positive-pressure breaths, the mask must fit snugly with no leakage. The BiPAP device delivers positive-pressure ventilation to keep alveoli open and prevent atelectasis. It promotes rhythmic breathing and prevents apneic episodes, which cause dyspnea, thereby promoting comfort and restful sleep. It delivers oxygen as well as room air. The difference and benefit of BiPAP over the continuous positive airway pressure (CPAP) machine is that exhalation pressure is less than inspiratory pressure in BiPAP, providing less resistance and enhanced comfort.

Immediately after having a tracheostomy tube removed as ordered by the provider, the patient begins to cough and has difficulty breathing, talking, and clearing secretions. After notifying the provider, the nurse anticipates an order for which procedure? 1 Reintubation 2 Tracheal dilation 3 Insertion of an oral airway 4 Placement of a nasogastric tube

2 Tracheal dilation This patient shows signs of tracheal stenosis characterized by increased cough, difficulty breathing and talking, and decreased ability to clear secretions. Tracheal dilation is usually necessary to open the trachea. Insertion of an oral airway does not open the trachea. Placement of a nasogastric tube is not indicated. Reintubation will make the tracheal stenosis worse.

Which cuff pressure should be maintained in a tracheostomy or endotracheal tube to prevent mucosal ischemia? 1 4-8 mm Hg 2 10-12 mm Hg 3 14-20 mm Hg 4 22-28 mm Hg

3 14-20 mm Hg A pressure range of 14-20 mm Hg is recommended to prevent an air leak around the cuff yet not be excessive to cause ischemia of the tracheal mucosa. Pressures below 14 mm Hg may lead to air leakage around the cuff. Pressures above 20 mm Hg can lead to ischemia of the tracheal mucosa.

The patient with a tracheostomy who is using a T-piece mask reports a feeling of suffocation to the nurse. What is the first intervention that the nurse adopts in order to provide relief to the patient? 1 Empty condensation from the tubing. 2 Make sure that the humidifier creates enough mist. 3 Check that the exhalation port is open and uncovered. 4 Position the T-piece so that it does not pull on the tracheostomy.

3 Check that the exhalation port is open and uncovered. The possible reason for the patient's feeling of suffocation could be occlusion of the exhalation port. So, to stabilize the patient's condition, the nurse should open the port and keep the port uncovered. The flow rate delivery of fraction of inspired oxygen (FiO 2) is affected by condensation. The humidifier should create enough mist to be visible during inspiration and expiration. If the weight of the T-piece pulls on the tracheostomy, it causes pain or erosion of skin at the insertion site; therefore, it is essential to see to it that it does not pull on the tracheostomy.

Which of these oxygen delivery systems is known to deliver low-flow fraction of inspired oxygen (FiO 2)? 1 Face tent 2 Venturi mask 3 Nasal cannula 4 Tracheostomy

3 Nasal cannula The nasal cannula is the only type of oxygen delivery system which delivers low-flow FiO 2. Face tents, Venturi masks, and tracheostomies are examples of oxygen delivery systems that deliver high-flow FiO 2.

A patient with a new tracheostomy has a soiled dressing. What is the best nursing intervention? 1 Reinforce the dressing with sterile 4 × 4 gauze. 2 Replace the dressing with clean, folded 4 × 4 gauze. 3 Replace the dressing with sterile, folded 4 × 4 gauze. 4 Cut sterile 4 × 4 gauze to fit around the tracheostomy tube.

3 Replace the dressing with sterile, folded 4 × 4 gauze. Tracheostomy dressings may be used to keep the tracheostomy clean and dry. These dressings resemble a 4 × 4 gauze pad with an area removed to fit around the tube. If tracheostomy dressings are not available, fold standard sterile 4 × 4s to fit around the tube. The dressing should never be cut because small bits of gauze could then be aspirated through the tube. Dressings should be changed often because moist dressings provide a medium for bacterial growth, leading to infection.

Which instance would make the treatment with continuous positive airway pressure (CPAP) ineffective? 1 Atelectasis after surgery 2 Cardiac-induced pulmonary edema 3 Respiratory failure following extubation 4 Chronic obstructive pulmonary disease (COPD)

3 Respiratory failure following extubation CPAP has been found ineffective for patients with respiratory failure following extubation. Atelectasis is commonly seen in patients who have undergone surgery. Patients with cardiac-induced pulmonary edema and COPD may benefit from this form of oxygen or air delivery.

To prevent aspiration during swallowing in a patient with a tracheostomy, what does the nurse suggest? 1 Hold the head high when swallowing. 2 Consume consecutive swallows of liquids. 3 Thicken all liquids to increase consistency. 4 Include moisture-producing fruits in the diet.

3 Thicken all liquids to increase consistency. Thickening the consistency of all liquids will facilitate swallowing with a decreased risk of aspiration. The patient should actually "tuck" the chin down and move the forehead forward when swallowing. Consecutive swallows of liquid will likely increase the risk of aspiration as would consuming moisture-producing fruits.

What is the greatest priority while providing care to a patient with a tracheostomy? 1 Ensuring the area behind the faceplate is kept clean and dry 2 Assessing for redness and skin breakdown around the tracheostomy 3 When changing the ties, having someone assist by holding the tube until it is securely stable 4 Encouraging the patient and family members to participate in tracheostomy care

3 When changing the ties, having someone assist by holding the tube until it is securely stable Unless the tube is well secured when providing tracheostomy care and changing the ties, dislodgement or decannulation may occur. Potential loss of airway is a priority over potential for skin breakdown or patient/family teaching.

A patient who is concerned about getting a tracheostomy says, "I will be ugly with a hole in my neck." What is the nurse's best response? 1 "It won't take you long to learn to manage." 2 "But you know you need this to breathe, right?" 3 "Your family and friends probably won't even care." 4 "Do you have a scarf or a large loose collar that you could place over it?"

4 "Do you have a scarf or a large loose collar that you could place over it?" Suggesting strategies to cover the tracheostomy recognizes patient concerns and explores options for dealing with the effects of the procedure. Reiterating the reason for the tracheostomy, suggesting that the patient's loved ones won't care, and telling the patient that he or she will learn to live with the tracheostomy are insensitive responses and minimize the patient's concerns.

The spouse of a patient who is scheduled for a tracheostomy is expressing concern regarding the surgery's impact on their quality of life. What should the focus of the nurse be at this time? 1 Providing information about how to perform emergency resuscitation 2 Emphasizing just getting through the surgery and postoperative period 3 Teaching about the techniques explained previously for tracheostomy care 4 Addressing approaches for the patient to communicate with the tracheostomy

4 Addressing approaches for the patient to communicate with the tracheostomy Various methods of nonverbal communication should be tried to determine the best approach to allow the couple to discuss their concerns and approaches for maintaining quality of life. Although it is important for the spouse to learn tracheostomy care and emergency procedures like resuscitation, concern for quality of life will potentially interfere with mastery of the content and skills.

The nurse assesses a patient who is receiving oxygen using a partial rebreather facemask at a flow rate of 12 L/min. The nurse notes the patient's oxygen saturation level is 90%. Which action would the nurse take next? 1 Obtain arterial blood gases. 2 Notify the Rapid Response Team. 3 Increase the oxygen flow rate to 15 L/min. 4 Change the mask to a non-rebreather mask.

4 Change the mask to a non-rebreather mask. Patients receiving oxygen by mask are prone to rebreathing exhaled air containing carbon dioxide and room air that has a lower oxygen concentration. A non-rebreather mask can deliver an FiO 2 greater than 90% at a flow rate of 10-15 L/min. Blood gases are not necessary in a patient with a saturation of 90%. There is no indication of respiratory instability in the patient described, so the Rapid Response Team is not needed. The partial rebreather only allows an oxygen flow rate of 6-11 L/min., so an increase to 12 L/min is not a correct action.

Which finding indicates a need for low-flow oxygen delivery for a patient? 1 Acute hypoxia 2 Chronic hypoxia 3 Acute hypercarbia 4 Chronic hypercarbia

4 Chronic hypercarbia Patients with chronic hypercarbia need lower levels of oxygen delivery since a low PaO 2 level is this patient's primary stimulus for breathing. High-flow oxygen delivery will cause oxygen-induced hypoventilation and CO 2 narcosis. Patients with any level of hypoxia should have oxygen flow levels of 2-4 L/min. Patients with acute hypercarbia may have high-flow oxygen without a risk of oxygen-induced hypoventilation.

The nurse discovers that a patient's tracheostomy tube has an air leak and notes a cuff pressure of 20 mm Hg. Which action by the nurse is correct? 1 Inflate the cuff to a pressure of 20-30 mm Hg. 2 Secure the outer cannula of the tracheostomy with tape. 3 Suction the patient more often to prevent frequent coughing. 4 Contact the provider to request a larger-diameter tracheostomy tube.

4 Contact the provider to request a larger-diameter tracheostomy tube. The tracheostomy cuff should be inflated to a pressure of 14-20 mm Hg, or 20-30 cm H 2O. If the patient continues to show signs of an air leak after properly inflating the cuff, a larger-diameter tube should be used. A range of 20-30 is the range of cm H 2O, not mm Hg. Securing the cannula with tape or suctioning the patient frequently does not prevent an air leak.

The lunch tray is served to a patient wearing a Venturi mask. What does the nurse do to facilitate eating? 1 Substitute a face tent for use at mealtime. 2 Teach the patient to lift the lower edge of the mask with each bite of food. 3 Increase the flow rate, loosen the strap, and allow the mask to drop down around neck. 4 Request a prescription for a nasal cannula to only be used during mealtime.

4 Request a prescription for a nasal cannula to only be used during mealtime. It is recommended that a nasal cannula be obtained during mealtime to allow the patient to be comfortable when eating while maintaining adequate oxygenation. The other choices do not maintain consistency in oxygen blood levels nor promote comfort.

A patient who has experienced a panic attack is being transferred to the medical-surgical ward. The transfer nurse reports that the patient is doing much better after receiving bronchodilators via nebulizer and a small dose of oral diazepam 4 hours ago in the emergency department. Vital signs are stable with oxygen delivered at 4 L/min via simple facemask. Why is this patient at high risk for subsequent respiratory distress? 1 The patient has a mental disorder. 2 The patient received a dose of diazepam. 3 The patient is not being treated for asthma. 4 The patient is receiving oxygen at 4 L/min.

4 The patient is receiving oxygen at 4 L/min. A simple facemask must receive oxygen at a rate of at least 5 L/min to prevent inhalation of exhaled breath, which has low levels of oxygen and can eventually suffocate the patient. The patient had a panic attack, not an asthma attack. A panic attack is not a definitive diagnostic indicator of a mental disorder. A small dose of diazepam does not place a patient at increased risk for respiratory distress; a large dose is required to place a patient at high risk.

Which medical emergency can lead to a life-threatening situation? 1 Tracheomalacia 2 Tracheal stenosis 3 Tracheoesophageal fistula (TEF) 4 Trachea-innominate artery fistula

4 Trachea-innominate artery fistula In trachea-innominate artery fistula, a malpositioned tube triggers its distal tip to push against the lateral wall of the tracheostomy. This pressure causes necrosis and erosion of the innominate artery, resulting in massive bleeding, which is life-threatening. In tracheomalacia, there is constant pressure exerted by the cuff, which results in tracheal dilation and erosion of cartilage. Tracheal stenosis is characterized by narrowed tracheal lumen. It is formed due to scar formation from irritation of tracheal mucosa by the cuff. TEF is caused by excessive cuff pressure that leads to erosion of the posterior wall of the trachea.

While performing care for a patient who had a tracheostomy placed 24 hours ago, the tube is accidentally dislodged. What action is the highest priority for the nurse? 1 Attempt to replace the tube. 2 Assess vital signs including respiratory rate. 3 Assess for bilateral breath sounds. 4 Ventilate with a resuscitation bag and mask.

4 Ventilate with a resuscitation bag and mask. The highest priority in the situation where a tracheostomy tube that is less than 48 hours old becomes dislodged is to oxygenate the patient with a bag and facemask while another nurse calls the Rapid Response Team. The nurse should not attempt to replace the tube in this situation because damage may occur. Assessing for vital signs is done after bag/valve mask resuscitation is started and the Rapid Response team is notified. Assessing for bilateral breath sounds is done after the tube is replaced to ensure proper tube placement.