Module 2 Chapter 28 Care of Patients Requiring Oxygen Therapy or Tracheostomy

4 NPPV should be used only in clients with intact mental status who can protect their airway. Both the ventilator and NPPV have advantages and risks. A major concern in clients on NPPVs is that they must be alert enough to protect their own airway; mental status would be a key determining factor. Either system can be used to treat dyspnea or hypercarbia. The need for PEEP is not known at this time.

A client's family is asking about the comparative risks with a ventilator versus noninvasive positive pressure ventilation (NPPV). Which principle should guide the nurse's response? 1 A ventilator is preferred; it will be required if the problem is dyspnea or hypercarbia. 2 The positive pressure aspect of NPPV will provide for the client's current oxygenation. 3 The client most likely requires positive end-expiratory pressure (PEEP), and would need a ventilator for adequate response. 4 NPPV should be used only in clients with intact mental status who can protect their airway.

2 Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask.

A new graduate RN discovers that her client, who had a tracheostomy placed the previous day, has completely dislodged both the obturator and the tracheostomy tube. Which action should the nurse take first? 1 Auscultate the client's breath sounds while applying a nasal cannula. 2 Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask. 3 Apply a 100% non-rebreather mask while administering high-flow oxygen. 4 Replace the obturator while reinserting the tracheostomy tube.

3 Keep the pressure on the tracheal tube cuff between 14 and 20 mm Hg. Older clients and those who are malnourished and dehydrated are at increased risk for tissue breakdown caused by tracheostomy tube pressure. Anything that causes movement of the tube causes friction and can contribute to tissue breakdown. Maintenance of cuff pressure between 14 mm Hg and 20 mm Hg will allow adequate circulation to the tracheal mucosa. The nurse should change dressings and suction the tube only as needed, taking care not to move the tube. Coughing will increase tube friction. Test-Taking Tip: Many times the correct answer is the longest alternative given, but do not count on it. Item writers (those who write the questions) are also aware of this and attempt to avoid offering you such "helpful hints."

An older client receiving mechanical ventilation with a tracheostomy has poor nutritional status and is dehydrated. Which nursing action is most important to prevent complications in this client? 1 Change the tracheostomy tube dressing and reposition the tube every 4 hours. 2 Encourage the client to cough frequently to clear secretions. 3 Keep the pressure on the tracheal tube cuff between 14 and 20 mm Hg. 4 Provide warm, humidified air and suction the tube frequently.

1 Hyperoxygenate before and after suctioning. The client should be preoxygenated with 100% oxygen for 30 seconds to 3 minutes to prevent hypoxemia. After suctioning, the client should be hyperoxygenated for 1-5 minutes, or until the client's baseline heart rate and oxygen saturation are within normal limits. Repeat suctioning as needed for up to three total suction passes; additional suctioning will cause or worsen hypoxemia. Applying suction during insertion is inappropriate because suction makes advancement of the suction tube difficult/traumatic. Suction is applied only when the suction tube is removed. Suctioning for 30 seconds is too long and can cause or worsen hypoxemia; never suction longer than 10-15 seconds.

For client safety and quality care, which technique is best for the nurse to use when suctioning the client with a tracheostomy tube? 1 Hyperoxygenate before and after suctioning. 2 Repeat suctioning until the tube is clear. 3 Apply suction during insertion of the tube. 4 Suction for 30 seconds.

4 Tracheal dilation This client 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. Test-Taking Tip: Read carefully and answer the question asked; pay attention to specific details in the question.

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

1 Simple facemask 3 Nonrebreather mask Both simple and non-rebreather facemasks can deliver a low level of oxygen. The Venturi (or Venti) and aerosol masks are used in high-flow oxygen delivery systems, and are set up to deliver 24% to 50% Fio2 and 24% to 100% Fio2 respectively. The T-piece apparatus is an adapter that is attached to an endotracheal or tracheostomy tube.

Low-flow oxygen delivery systems typically include which types of components? Select all that apply. 1 Simple facemask 2 Venturi mask 3 Nonrebreather mask 4 Aerosol mask 5 T-piece apparatus

1 Tight-fitting masks can lead to skin breakdown. 3 Mask leaks can cause pressure around the eyes. 4 There is a risk of aspiration due to gastric inflation. 5 NPPV may require nasal gastric tube placement. NPPV masks must fit tightly in order to form a proper seal, which can lead to skin breakdown over the bridge of the nose or other areas of the face. Leaks can cause uncomfortable pressure around the eyes, and gastric insufflation can lead to vomiting and the potential for aspiration. A nasogastric tube may be required for safety. Ventilator-associated pneumonia is a risk associated with intubation, not NPPV.

The health care provider has suggested placing a client with chronic obstructive pulmonary disease (COPD) on noninvasive positive-pressure ventilation (NPPV) to improve gas exchange. What information is important to discuss with the client before starting NPPV? Select all that apply. 1 Tight-fitting masks can lead to skin breakdown. 2 Pneumonia is a common associated risk. 3 Mask leaks can cause pressure around the eyes. 4 There is a risk of aspiration due to gastric inflation. 5 NPPV may require nasal gastric tube placement. NPPV masks must fit tightly in order to form a proper seal, which can lead to skin breakdown over the bridge of the nose or other areas of the face. Leaks can cause uncomfortable pressure around the eyes, and gastric insufflation can lead to vomiting and the potential for aspiration. A nasogastric tube may be required for safety. Ventilator-associated pneumonia is a risk associated with intubation, not NPPV.

1 Attach a warming device to the humidification water source. 2 Ensure intake of fluids is adequate. 4 Increase the flow rate of the air flow meter. A warming device enhances humidification. When a client is adequately hydrated, tracheal secretions are thinner. Increasing the flow rate increases the passage of air through the humidifier and enhances humidification. It is not within the nurse's scope of practice to instill water into the tracheostomy. Condensation should be drained away from the airway to protect from aspiration and infection.

The nurse is caring for a client with a tracheostomy and a T-piece who has thick tracheal secretions. What does the nurse do to liquefy secretions and facilitate suctioning? Select all that apply. 1 Attach a warming device to the humidification water source. 2 Ensure intake of fluids is adequate. 3 Periodically instill 10 mL of sterile water into the tracheostomy. 4 Increase the flow rate of the air flow meter. 5 Drain condensation in the tubing back toward the tracheostomy

1 Bradycardia 2 Heart block 5 Asystole Tracheal suctioning can cause a vagal response. This stimulus influences the electrical system of the heart, potentially leading to decreased heart rate (bradycardia), heart block, asystole, or other dysrhythmias. Bronchospasm would not be induced by this type of stimulus. Vagal stimulation can result in hypotension, not hypertension.

Vagal stimulation during suctioning can contribute to which conditions? Select all that apply. 1 Bradycardia 2 Heart block 3 Bronchospasm 4 Hypertension 5 Asystole

2 High levels of oxygen dilute the nitrogen in the lungs leading to alveolar collapse. Correct 5 Nitrogen helps prevent alveolar collapse, as it doesn't cross over capillary membranes. Nitrogen, which is 79% of room air, helps to prevent alveolar collapse because it doesn't cross over the capillary membranes into the blood. High levels of oxygen administration dilute the nitrogen when it diffuses across the membrane into the circulation, and the alveoli collapse, leading to atelectasis. Oxygen administration can cause toxicity and must be monitored closely. An increased Paco2 will result when the client is retaining CO2; this is not a desirable state. Pao2 levels of greater than 90 mm Hg should be reported to the health care provider.

Which principles are important for the nurse to remember about oxygen administration? Select all that apply. 1 Oxygen is harmless; it is part of what we breathe normally and toxicity is unlikely. 2 High levels of oxygen dilute the nitrogen in the lungs leading to alveolar collapse. 3 When a client experiences air hunger, increase the Paco2 to improve the balance. 4 It is important to keep the client's Pao2 at greater than 90 mm Hg for optimal outcomes. 5 Nitrogen helps prevent alveolar collapse, as it doesn't cross over capillary membranes.

4 Ensure portable oxygen is in place before transport to radiology. Oxygen is a drug and should not be interrupted. It is the nurse's responsibility to ensure that the client has an oxygen source during periods of transport so that oxygen delivery is not disrupted. A portable x-ray is not necessary if the client is ambulatory. Neither hyperoxygenating nor disconnecting the oxygen is safe practice. Test-Taking Tip: Eat breakfast or lunch before an exam. Avoid greasy, heavy foods and overeating. This will help keep you calm and give you energy.

A chest x-ray is ordered for an ambulatory client receiving nasal oxygen. What does the nurse do when transport personnel come to get the client? 1 Since the client will only be gone briefly, turn the oxygen off and then resume immediately upon return. 2 Call radiology and request that a portable chest x-ray be done at the bedside. 3 Turn the oxygen rate up briefly before disconnecting for transport. 4 Ensure portable oxygen is in place before transport to radiology.

3 "Our grandson will blow out the birthday candles for her at the party." Oxygen is combustible and open flames like matches and candles should not be used in the immediate vicinity. Smoking should not be allowed in the same room when oxygen is in use. Knowing how to use a fire extinguisher correctly is important. The client should return to the hospital for further evaluation if respiratory distress develops. Test-Taking Tip: Read carefully and answer the question asked; pay attention to specific details in the question.

A client being discharged home after being diagnosed with chronic obstructive respiratory syndrome (COPD) will require home oxygen therapy. Which statement by the client's spouse indicates that further teaching is required? 1 "We will not allow smoking at our home." 2 "We have several fire extinguishers, and we know how to use them." 3 "Our grandson will blow out the birthday candles for her at the party." 4 "We will return to the hospital if she seems to be having trouble breathing."

3 Speech therapy A vital member of the multidisciplinary team for the patient with a fenestrated tracheostomy tube is Speech Therapy. Speech therapy can teach the patient about swallowing and communication. Helping communication is an important nursing action and is National Patient Safety Goal set forth by The Joint Commission. Physical therapy and occupational therapy may be beneficial to the patient for conditioning and strengthening. The patient may utilize a patient care assistant as well. Study Tip: The old standbys of enough sleep and adequate nutritional intake also help keep excessive stress at bay. Although nursing students learn about the body's energy needs in anatomy and physiology classes, somehow they tend to forget that glucose is necessary for brain cells to work. Skipping breakfast or lunch or surviving on junk food puts the brain at a disadvantage.

A client has a fenestrated tracheostomy tube in place. Which of the following multidisciplinary team members should be involved in the discharge planning process? 1 Physical therapy 2 Occupational therapy 3 Speech therapy 4 Patient care assistant

3 Listen to lung sounds. The first nursing action for a client following an airway procedure is to assess the client's respiratory status; this requires auscultation of the lungs. Suction is not needed if the lungs are clear to auscultation. Although cleanliness is a priority, the nurse must assess the client's respiratory status before cleaning or performing a dressing change.

A client has just arrived in the postanesthesia care unit (PACU) following a successful tracheostomy procedure. Which nursing action must be taken first? 1 Suction as needed. 2 Clean the tracheostomy inner cannula and stoma. 3 Listen to lung sounds. 4 Change the tracheostomy dressing as needed.

1 Face tent A client with smoke inhalation and facial burns who requires high-flow oxygen should initially be placed on a face tent because this is the only noninvasive high-flow device that will minimize painful and contaminating contact with burned facial tissue. Although a Venturi mask and a non-rebreather mask are high-flow oxygen delivery devices, they require snug fitting on the face, which can be painful and can introduce infection to compromised facial skin. A nasal cannula is not a high-flow device.

A client has just been admitted to the emergency department and requires high-flow oxygen therapy after suffering facial burns and smoke inhalation. Which oxygen delivery device should the nurse use initially? 1 Face tent 2 Venturi mask 3 Nasal cannula 4 Non-rebreather mask

2 Non-rebreather mask Non-rebreather masks allow the highest oxygen level of the low-flow systems and are often used for clients whose respiratory status is unstable and who may require intubation. The facemask and the partial rebreather mask are used for clients who are more stable. The Venturi mask is used for clients with chronic lung disease to allow for precise oxygen delivery. Test-Taking Tip: Do not read too much into the question or worry that it is a "trick." If you have nursing experience, ask yourself how a classmate who is inexperienced would answer this question from only the information provided in the textbooks or given in the lectures.

A client is being admitted with severe respiratory distress and will require an Fio2 greater than 80%. Prior to possible intubation and mechanical ventilation, the nurse anticipates using which oxygen delivery equipment? 1 Facemask 2 Non-rebreather mask 3 Partial rebreather mask 4 Venturi mask

1 "I can only take baths, but no showers." The client does not understand that he or she can shower with the use of a shower shield over the tracheostomy tube to prevent water from entering the airway. Additional teaching is necessary. Normal saline should be instilled into the artificial airway 10-15 times a day, as prescribed. The stoma should be covered with cotton or foam to protect it during the day; this filters the air entering the stoma, keeps humidity in the airway, and enhances appearance. Clients with tracheostomies should be taught clean suction technique.

A client is being discharged home with a tracheostomy. Which statement by the client indicates the need for further teaching about correct tracheostomy care? 1 "I can only take baths, but no showers." 2 "I can put normal saline in my tracheostomy to keep the secretions from getting thick." Incorrect3 "I should put cotton or foam over the tracheostomy hole." 4 "I will have to learn to suction myself."

3 Use of a heated humidifier or nebulizer 4 Use of an oral suction catheter in the endotracheal tube Humidifiers and nebulizer containers can harbor organisms, which can lead to infections in clients receiving oxygen therapy. Organisms in the oral cavity can cause respiratory infections when transferred to the trachea via a suction catheter. Although oxygen tubing tension on an airway can cause pressure and potential breakdown, the more immediate concerns are the heated fluid in the containers and transference via suction catheters. The nonpetroleum lotions are preferred for dry skin that can result from oxygen therapy. A rise in the white blood cell count may indicate the presence of an infection, but it is not a source of infection.

A client is receiving oxygen therapy. What are potential sources of infection the nurse should address? Select all that apply. 1 Oxygen tubing pulling on the airway 2 Use of nonpetroleum lotion for dry skin 3 Use of a heated humidifier or nebulizer 4 Use of an oral suction catheter in the endotracheal tube 5 Rising white blood cell count noted on recent blood work Humidifiers and nebulizer containers can harbor organisms, which can lead to infections in clients receiving oxygen therapy. Organisms in the oral cavity can cause respiratory infections when transferred to the trachea via a suction catheter. Although oxygen tubing tension on an airway can cause pressure and potential breakdown, the more immediate concerns are the heated fluid in the containers and transference via suction catheters. The nonpetroleum lotions are preferred for dry skin that can result from oxygen therapy. A rise in the white blood cell count may indicate the presence of an infection, but it is not a source of infection.

4 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.

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

2 Increase the oxygen flow rate to 5 L/min and review the provider's orders. A minimum flow rate of 5 L/min is needed for clients receiving oxygen via facemask to prevent the rebreathing of exhaled air. The nurse should increase the flow rate to this minimum level and then check the order. The nurse will assess the client at regular intervals after ensuring the safe delivery of oxygen. If the client can be weaned from oxygen, a nasal cannula will be used to prevent rebreathing of exhaled air. Asking the client to sit up and take deep breaths is not necessary since the client has an adequate respiratory rate and oxygen saturation. Study Tip: Answer every question. A question without an answer is the same as a wrong answer. Go ahead and guess. You have studied for the test and you know the material well. You are not making a random guess based on no information. You are guessing based on what you have learned and your best assessment of the question.

A client receiving oxygen via a simple facemask has a pulse oximetry level of 96% and a respiratory rate of 14 breaths per minute. Oxygen is being delivered at a flow rate of 4 L/min. What is the correct action by the nurse? 1 Assess the client at 30- to 60-minute intervals for evaluation of oxygenation status. 2 Increase the oxygen flow rate to 5 L/min and review the provider's orders. 3 Request an order to decrease the flow rate to see if the client can wean from oxygen. 4 Suggest that the client sit up straight and take several deep, slow breaths.

1 "A fenestrated tube is necessary to facilitate talking." Fenestrated tubes allow airflow across the vocal cords, thus allowing the client to talk. Simply telling the client that the tube is necessary does not offer the client information as to why. Clients with cuffless tubes can also talk. Unless there is permanent damage to the vocal cords, clients will be able to speak. Test-Taking Tip: Key words or phrases in the stem of the question such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. As in life, no real absolutes exist in nursing; however, every rule has its exceptions, so answer with care.

A client who has a long-term tracheostomy communicates frustration to the nurse about not being able to talk. What does the nurse tell this client? 1 "A fenestrated tube is necessary to facilitate talking." 2 "Cuffed tracheostomy tubes are necessary." 3 "Until the tube is out, you will not be able to speak." 4 "You may never be able to speak again."

3 When the mask was changed at the end of the previous shift, a simple facemask was initiated for oxygen delivery. The Venturi mask is for high-flow oxygen therapy; if it was switched to a simple facemask, the client would likely notice the difference in oxygen delivery. A Venturi mask does not have a rebreather bag or a nonrebreather bag. The reported problem is most likely related to not using a high-flow oxygen delivery system, rather than the size of the mask. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options. Example: If the item relates to and identifies stroke rehabilitation as its focus and only one of the options contains the word stroke in relation to rehabilitation, you are safe in identifying this choice as the correct response.

A client who has been receiving high-flow oxygen via a Venturi mask for several days is reporting respiratory difficulty and that the mask doesn't seem right. What cause could be contributing to this sensation? 1 The rebreather bag on the mask has water accumulated in it, thus decreasing the volume of oxygen available. 2 The flaps over the exhalation ports on the nonrebreather bag are not opening and closing as the client breathes. 3 When the mask was changed at the end of the previous shift, a simple facemask was initiated for oxygen delivery. 4 The mask now being used is too large for the client's face.

4 The client 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 client. The client 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 Valium does not place a client at increased risk for respiratory distress; a large dose is required to place a client at high risk.

A client who has experienced a panic attack is being transferred to the medical-surgical ward. The transfer nurse reports that the client is doing much better after receiving bronchodilators via nebulizer and a small dose of oral Valium 4 hours ago in the emergency department. Vital signs are stable with oxygen delivered at 4 L/min via simple facemask. Why is this client at high risk for subsequent respiratory distress? 1 The client is not being treated for asthma. Incorrect2 The client has a mental disorder. 3 The client received a dose of Valium. 4 The client is receiving oxygen at 4 L/min.

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

A client 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 "But you know you need this to breathe, right?" 2 "Do you have a scarf or a large loose collar that you could place over it?" 3 "Your family and friends probably won't even care." 4 "It won't take you long to learn to manage."

2 Deflating the cuff An inflated cuff with a capped fenestration tube gives the client no airway. Deflating the cuff around the tube will help relieve this. If the client does not improve with cuff deflation, then the cap should be removed. The health care provider should be notified of any further problems. Auscultating breath sounds determines if the tube is in place and might be necessary, but it is not the most important first action. Test-Taking Tip: Practicing a few relaxation techniques may prove helpful on the day of an examination. Relaxation techniques such as deep breathing, imagery, head rolling, shoulder shrugging, rotating and stretching of the neck, leg lifts, and heel lifts with feet flat on the floor can effectively reduce tension while causing little or no distraction to those around you. It is recommended that you practice one or two of these techniques intermittently to avoid becoming tense. The more anxious and tense you become, the longer it will take you to relax.

A client with a cuffed fenestrated tracheostomy tube has been speaking well when the decannulation cap is in place. While visiting, the family alerts the nurse that the client is having difficulty breathing. Which action by the nurse has the highest priority? 1 Calling the health care provider 2 Deflating the cuff 3 Removing the cap 4 Auscultating the breath sounds

2 The pilot balloon is flat. The cuff must be deflated before placing the decannulation cap; otherwise, there will be no airway. The pilot balloon is the external indicator that the cuff is deflated. The tracheostomy still needs to be stabilized with straps or ties. If the tracheostomy is capped, there is no inlet for administering oxygen. Since the client is using the natural airway, a cannula or mask is used to administer oxygen. Test-Taking Tip: Monitor questions that you answer with an educated guess or changed your answer from the first option you selected. This will help you to analyze your ability to think critically. Usually your first answer is correct and should not be changed without reason.

A client with a tracheostomy has been weaned off of the mechanical ventilator and now has a decannulation cap over the end of the tracheostomy tube. What additional finding does the nurse note when assessing the client? 1 The tracheostomy cuff is inflated. 2 The pilot balloon is flat. 3 Tracheostomy ties are no longer needed to stabilize the tracheostomy tube. 4 A tracheostomy collar provides humidified oxygen.

2 Placement of a jejunostomy tube. This client has signs of a tracheoesophageal fistula (TEF) where excessive cuff pressure causes an erosion of the posterior wall of the trachea and into the anterior esophagus. Clients who develop this should either be fed with a very small-bore feeding tube or should have surgical placement of a gastrostomy or jejunostomy tube. A fenestrated tracheostomy tube is used to facilitate coughing or speaking. Placing a larger tracheostomy tube will increase pressure on the tracheal wall. The trachea does not need to be dilated. Test-Taking Tip: Read every word of each question and option before responding to the item. Glossing over the questions just to get through the examination quickly can cause you to misread or misinterpret the real intent of the question.

A client with a tracheostomy is receiving feedings via a nasogastric tube, during which the client experiences increased coughing and choking. The nurse notes that the tracheostomy cuff requires increasing amounts of air to maintain the seal, and when suctioning the tracheostomy, food particles are present in the tracheal secretions. After notifying the provider of these observations, which procedure does the nurse expect to be performed? 1 Insertion of a fenestrated tracheostomy tube. 2 Placement of a jejunostomy tube. 3 Reintubation with a larger tracheostomy tube. 4 Tracheal dilatation in the operating room.

2 Change the humidification device to a heated nebulizer. All clients receiving oxygen should have humidification to help minimize tissue trauma. Clients receiving oxygen through an artificial airway should have heated humidification to increase the humidity level. If the client were receiving oxygen without an artificial airway, the water would be at an appropriate level and should be bubbling to be effective. Even though humidity increases the risk of infection, the correct action is to follow protocol for changing the equipment to prevent infection. Study Tip: Establish your study priorities and the goals by which to achieve these priorities. Write them out and review the goals during each of your study periods to ensure focused preparation efforts.

A client with an artificial airway is receiving oxygen at a rate of 4 L/min. The nurse notes that a humidifier bottle between the oxygen source and the client is half-full of sterile water and that the water is bubbling. Which action by the nurse is correct? 1 Add water to the humidifier bottle until the water stops bubbling. 2 Change the humidification device to a heated nebulizer. 3 Increase the oxygen flow to 6 L/min to ensure adequate humidification. 4 Remove the humidification device to minimize the risk of infection.

1 Adjust the position of the oxygen tubing. The scope of a nursing assistant's work includes positioning of oxygen tubing for client comfort. Assessing for signs and symptoms of hypoventilation, choosing which O2 delivery device to use, and changing the O2 flow rate are actions that are beyond the scope of practice for unlicensed personnel.

A client with chronic obstructive pulmonary disease (COPD) has a physician's prescription stating, "Adjust oxygen to keep SpO2 at 90% to 92%." Which nursing action can be delegated to a nursing assistant working under the supervision of an RN? 1 Adjust the position of the oxygen tubing. 2 Assess for signs and symptoms of hypoventilation. 3 Change the O2 flow rate to keep SpO2 as prescribed. 4 Choose which O2 delivery device should be used for the client.

4 Noninvasive positive-pressure ventilation Noninvasive positive-pressure ventilation helps keep airways open and improves gas exchange without the need for airway intubation. It is especially useful for clients with COPD. An aerosol facemask provides high-flow, high-humidity oxygen, which would not be helpful for the client with an obstructive process. A Venturi mask may be used in clients with COPD who are stable, but this client is not stable. Intubation is a last resort after other methods fail. Study Tip: Develop a realistic plan of study. Do not set rigid, unrealistic goals.

A client with chronic obstructive pulmonary disease (COPD) is exhibiting increasing air hunger. The client is receiving oxygen via nasal cannula at a flow rate of 2 L/min. The nurse contacts the provider to discuss which treatment option for this client? 1 Aerosol facemask 2 Venturi mask with oxygen at 4 L/min 3 Intubation and mechanical ventilation 4 Noninvasive positive-pressure ventilation

1 Change the nasal cannula to a Venturi mask. The client is not getting enough oxygen through the nasal cannula because the nares are narrowed and full of secretions. The nurse should change the delivery system to see if this improves. Increasing the flow rate will not help if the delivery route is compromised. Arterial blood gases may be performed if the client does not improve after changes in oxygen delivery. Suctioning the nares will increase irritation and narrowing of the nares. Test-Taking Tip: Stay away from other nervous students before the test. Stop reviewing at least 30 minutes before the test. Take a walk, go to the library and read a magazine, listen to music, or do something else that is relaxing. Go to the test room a few minutes before class time so that you are not rushed in settling down in your seat. Tune out what others are saying. Crowd tension is contagious, so stay away from it.

A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at a flow rate of 2 L/min via nasal cannula. The nurse notes an oxygen saturation of 89% after a previous level of 92%, and assesses swelling of both nares along with copious nasal discharge. What is the nurse's next action? 1 Change the nasal cannula to a Venturi mask. 2 Increase the oxygen flow rate to 4 L/min. 3 Request an order for arterial blood gases. 4 Suction the nares to clear nasal passages.

2 Decrease the oxygen to 2 L/min to improve respiratory rate. Clients with chronic hypercarbia are at risk for oxygen-induced hypoventilation. Clients with COPD are more likely to have chronic hypercarbia. This client has a slowed respiratory rate and an altered level of consciousness indicating hypoventilation, which can occur within the first 30 minutes of oxygen therapy. The nurse should reduce the oxygen flow to see if the respiratory rate improves. Although many clients with COPD become anxious with a facemask, this client is currently not demonstrating signs of anxiety. Increasing the oxygen flow will only increase the risk for hypoventilation. An arterial blood gas will be a part of the ongoing assessment, but will not distinguish between acute and chronic hypercarbia. Study Tip: Enhance your time-management abilities by designing a study program that best suits your needs and current daily routines by considering issues such as the following: (1) Amount of time needed; (2) Amount of time available; (3) "Best" time to study; (4) Time for emergencies and relaxation.

A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen with a Venturi mask at a rate of 3 L/min. Prior to initiating oxygen therapy, the client appeared anxious with gray skin, a respiratory rate of 24 breaths/min, and an oxygen saturation of 87%. After 15 minutes of oxygen therapy, the nurse observes the client resting with closed eyes, pink coloration, a respiratory rate of 12 breaths/min, and an oxygen saturation of 95%. Which action by the nurse is correct? 1 Change the Venturi mask to a nasal cannula to further reduce anxiety. 2 Decrease the oxygen to 2 L/min to improve respiratory rate. 3 Increase the oxygen to 4 L/min to improve oxygen saturation. 4 Request an order for arterial blood gases to evaluate for hypercarbia

3 Lung sounds may indicate absorption atelectasi High levels of oxygen delivery can result in collapsed alveoli and absorption atelectasis. PEEP can help alveoli remain properly inflated. High Pao2 levels may result in oxygen toxicity. The need for 100% oxygen delivery does not suggest that the client should be extubated; rather, it suggests that the client 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.

A client 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 Pao2 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 Pao2 level may result in oxygen toxicity. 2 The 100% oxygen delivery requirement indicates immediate extubation. 3 Lung sounds may indicate absorption atelectasis. 4 The level of oxygen delivery may indicate absorption atelectasis

1 The client with a resolving pulmonary embolus who is receiving oxygen at 6 L/min through a nasal cannula Orthopedic nurses are familiar with pulmonary emboli and with administration of oxygen through nasal cannulas. Orthopedic nurses do not specialize in chronic lung conditions; such care is best assigned to an RN with experience in chronic lung conditions and in the use of various home oxygen delivery devices and the use of various types of oxygen delivery equipment. Orthopedic nurses do not specialize in airway surgery; such care is best assigned to an RN with experience in postoperative tracheostomy care and tracheostomy collar care. Study Tip: Enhance your time-management abilities by designing a study program that best suits your needs and current daily routines by considering issues such as the following: (1) Amount of time needed; (2) Amount of time available; (3) "Best" time to study; (4) Time for emergencies and relaxation.

An RN from the orthopedic unit has been floated to the medical unit. Which client assignment for the floated RN is the best? 1 The client with a resolving pulmonary embolus who is receiving oxygen at 6 L/min through a nasal cannula 2 The client with chronic lung disease who is being evaluated for possible home oxygen use 3 The client with a newly placed tracheostomy who is receiving oxygen through a tracheostomy collar 4 The client with chronic bronchitis who is receiving oxygen at 60% through a Venturi mask

3 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 client to be comfortable when eating while maintaining adequate oxygenation. The other choices do not maintain consistency in oxygen blood levels nor promote comfort. Test-Taking Tip: Anxiety leading to an exam is normal. Reduce your stress by studying often, not long. Spend at least 15 minutes every day reviewing the "old" material. This action alone will greatly reduce anxiety. The more time you devote to reviewing past material, the more confident you will feel about your knowledge of the topics. Start this review process on the first day of the semester. Don't wait until the middle to end of the semester to try to cram information.

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

1 Oxygen administration will decrease the work of the heart to improve the delivery of oxygen to vital organs. Since the problem is with oxygen delivery, the immediate need is supplemental oxygen. Although the heart may work harder to improve delivery of the available oxygen, the administration of oxygen will decrease the stress on the heart. An increase in red blood cells would take longer to accomplish. Hypercarbia is not the stimulus for breathing in individuals without chronic lung disease. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

The normal balance of the body's oxygen intake and delivery system can be disrupted when there is a problem with normal oxygen delivery. Which statement is true in these situations? 1 Oxygen administration will decrease the work of the heart to improve the delivery of oxygen to vital organs. 2 Oxygen administration is not needed; the body can adapt with an increase in red blood cells for oxygen delivery. 3 Hypercarbia will provide the necessary stimulus to prevent dangerously low blood oxygen levels. 4 Oxygen will not cure the underlying disease adequately to prevent hypoxia; therefore, oxygen delivery is not indicated.

1 Auscultate the client's breath sounds bilaterally. The nurse should auscultate breath sounds and awaken the client initially in order to provide complete assessment information to the health care provider. The nurse should closely monitor clients receiving oxygen therapy for decreased rate and depth, which can indicate oxygen-induced hypoventilation. The nurse should notify the provider that this client has a lower-than-normal respiratory rate and shallow respirations, which can precipitate respiratory arrest. The facemask does not safely deliver oxygen at a rate less than 40%. Study Tip: Regular exercise, even if only a 10-minute brisk walk each day, aids in reducing stress. Although you may have been able to enjoy regular sessions at the health club or at an exercise class several times a week, you now may have to cut down on that time without giving up a set schedule for an exercise routine. Using an exercise bicycle that has a book rack on it at home, the YMCA, or a health club can help you accomplish two goals at once. You can exercise while beginning a reading assignment or while studying notes for an exam. Listening to lecture recordings while doing floor exercises is another option. At least a couple of times a week, however, the exercise routine should be done without the mental connection to school; time for the mind to unwind is necessary, too.

The nurse assesses a client who has begun receiving oxygen therapy of 40% via Venturi mask and notes pink lips and nailbeds, and a pulse oximetry value of 98%. The client is sleeping and has a heart rate of 76 beats per minute, a respiratory rate of 6 breaths per minute, and breaths are nonlabored and shallow. What is the nurse's correct initial response? 1 Auscultate the client's breath sounds bilaterally. 2 Elevate the head of the bed and awaken the client. 3 Notify the provider of the client's respiratory rate and breathing pattern. 4 Request an order to decrease the oxygen to 30% via facemask.

1 Elevate the head of the bed for at least 30 minutes after eating. The nurse should elevate the head of the bed during eating and for at least 30 minutes after eating to prevent aspiration and reflux. The client should be encouraged to take "dry swallows" between bites of food to clear the esophagus. Increasing the pressure puts pressure on the esophagus. Clients should take small amounts of fluids from a spoon to facilitate swallowing. Study Tip: Focus your study time on the common health problems that nurses most frequently encounter.

The nurse is assisting a client with a tracheostomy to eat. Which is an important nursing action to help the client swallow and avoid aspiration? 1 Elevate the head of the bed for at least 30 minutes after eating. 2 Encourage the client to avoid swallowing between bites of food. 3 Increase the pressure in the tracheostomy cuff to block food particles. 4 Offer fluids using a straw and avoid giving thickened fluids

1 Notify the health care provider immediately. This assessment finding indicates there is subcutaneous emphysema. The provider should be notified immediately because this can worsen as air spreads into the surrounding tissues of the face and chest. An occlusive pressure dressing will not correct this complication. Routine care of securing and protecting the tracheostomy does not address the problem. Test-Taking Tip: If the question asks for an immediate action or response, all the answers may be correct, so base your selection on identified priorities for action.

The nurse is caring for a client the day after tracheostomy placement and notes new swelling around the tube. When gently palpating the area, the nurse feels a crackling sensation. What is the appropriate response? 1 Notify the health care provider immediately. 2 Reevaluate in 2 hours as this is a normal finding after surgery. 3 Apply an occlusive pressure dressing around the tube. 4 Ensure the tracheostomy tube is well-secured and there is no tension

3 Provide a writing pad or laptop computer for communication. 4 Ensure tube feeding is administered at the prescribed rate. 5 Place a tracheostomy tube, obturator, and insertion tray at the bedside. A significant psychosocial need of the client with a tracheostomy is loss of oral communication due to the artificial airway being placed through the vocal cords. The client should therefore be provided with an alternative method of communication such as a writing tablet or device with a keyboard. The client with a new tracheostomy is unable to swallow and is NPO, so providing alternative nutrition (tube feedings) is a priority. The risk for accidental dislodgement or decannulation necessitates that the nurse be prepared by placing the necessary equipment for emergency intervention at the bedside. A neck immobilizer is not used postoperatively. Assistance with ADLs is provided as needed; the nurse can support the tracheostomy and tubing to prevent tension.

The nurse is caring for a client who had a tracheostomy placed 48 hours ago. What are important considerations when caring for this client? Select all that apply. 1 Ensure the neck immobilizer is securely in place at all times. 2 Assist the client with all ADLs to minimize strain on the surgical site. 3 Provide a writing pad or laptop computer for communication. 4 Ensure tube feeding is administered at the prescribed rate. 5 Place a tracheostomy tube, obturator, and insertion tray at the bedside.

3 Ventilate the client using a manual resuscitation bag with facemask. 5 Call the Rapid Response Team. When a newly placed tracheostomy tube comes out, the priority is to reestablish the airway. The nurse should manually ventilate the client while another nurse calls the Rapid Response Team. The nurse should not attempt to manually replace the tube. A nasal airway is not indicated in this situation. A nonrebreather mask does not provide ventilation, which is vital. Test-Taking Tip: If the question asks for an immediate action or response, all of the answers may be correct, so base your selection on identified priorities for action.

The nurse is performing wound care on a tracheostomy placed 48 hours ago. While replacing the ties, the client becomes agitated and moves unexpectedly, causing the tube to come out. Which actions does the nurse immediately take? Select all that apply. 1 Attempt to place the tracheostomy tube back into the surgical stoma. 2 Insert a nasal airway. 3 Ventilate the client using a manual resuscitation bag with facemask. 4 Provide 100% oxygen via a nonrebreather mask. 5 Call the Rapid Response Team.

1 Administer oxygen by simple facemask while suctioning the client. If hypoxia occurs while suctioning, the nurse should stop suctioning and reoxygenate the client with 100% oxygen and manual resuscitation until hypoxia improves before resuming suctioning. It may be necessary to provide oxygen during the procedure to prevent hypoxia, but this should not be done if hypoxia is present and not via a facemask if a tracheostomy is the airway for this client. In general, a larger-diameter tube increases the risk of hypoxia. It is not correct to ask the client to cough to improve hypoxia. Study Tip: Begin studying by setting goals. Make sure they are realistic. A goal of scoring 100% on all exams is not realistic, but scoring an 85% may be a better goal.

The nurse is suctioning a client who has a tracheostomy and notes a pulse oximetry reading of 90% during the procedure. Which action does the nurse take? 1 Administer oxygen by simple facemask while suctioning the client. 2 Change to a larger-diameter tube to facilitate removal of secretions. 3 Encourage the client to cough to assist with clearance of secretions. 4 Use a manual resuscitation bag to deliver 100% oxygen before resuming.

3 Picture board A picture board does not require very much dexterity for communication. Dexterity can be limited to the extent the client finds comfortable. A computer keyboard, Magic Slate, and pen and paper require dexterity that may be difficult and/or painful for a client with degenerative arthritis.

The older adult client with degenerative arthritis is admitted for tracheostomy surgery. What is the best communication method for this client during the postoperative period? 1 Computer keyboard 2 Magic Slate 3 Picture board 4 Pen and paper

1 Assess the client's respiratory status. The client must always be assessed before attention is turned to equipment. If the alarm is sounding as an indicator of worsening client condition, reducing the sensitivity is harmful. Suctioning the client may not even be needed; the client's respiratory status must be assessed before such a determination can be reached.

The peak pressure alarm is sounding on the ventilator of a client with a recent tracheostomy. What intervention should be done first? 1 Assess the client's respiratory status. 2 Decrease the sensitivity of the alarm. 3 Ensure that the connecting tubing is not kinked. 4 Suction the client.

4 Addressing approaches for the client 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. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Example: If you are being asked to identify a diet that is specific to a certain condition, your knowledge about that condition would help you choose the correct response (e.g., cholecystectomy = low-fat, high-protein, low-calorie diet).

The spouse of a client 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 Teaching about the techniques explained previously for tracheostomy care 2 Providing information about how to perform emergency resuscitation 3 Emphasizing just getting through the surgery and postoperative period 4 Addressing approaches for the client to communicate with the tracheostomy

3 Thicken all liquids to increase consistency. Thickening the consistency of all liquids will facilitate swallowing with a decreased risk of aspiration. The client 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. Test-Taking Tip: Look for options that are similar in nature. If all are correct, either the question is poor or all options are incorrect, the latter of which is more likely. Example: If the answer you are seeking is directed to a specific treatment and all but one option deal with signs and symptoms, you would be correct in choosing the treatment-specific option.

To prevent aspiration during swallowing in a client 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.

2 Hold the tracheostomy tube in place with one hand during the process. 3 Do not remove the old ties until the new ones are in place. Holding the tracheostomy tube in place with one hand during the process and not removing the old ties until the new ones are in place are two approaches to ensure that the tracheostomy tube does not become dislodged. Although it is important to know the tracheostomy tube size and type in case of dislodgement, it doesn't prevent decannulation during tie replacement. Having a coworker assist with the tie change is helpful, but does not directly prevent dislodgement like the other actions do. Manipulating the tracheostomy may trigger coughing; a cough suppressant is not likely to prevent this problem.

What actions prevent tracheostomy decannulation during tie replacement? Select all that apply. 1 Always have a coworker assist with the procedure. 2 Hold the tracheostomy tube in place with one hand during the process. 3 Do not remove the old ties until the new ones are in place. 4 Know the tracheostomy tube size and type if replacement is necessary. 5 Give the client a cough suppressant to prevent coughing.

1 Tube obstruction 2 Tube dislodgement 4 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 client would most likely not have an endotracheal tube.

What are typical postoperative concerns after a new tracheostomy? Select all that apply. 1 Tube obstruction 2 Tube dislodgement 3 Plugging the tube for communication 4 Accidental decannulation 5 Securing the endotracheal tube 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 client would most likely not have an endotracheal tube.

1 Ensure that aerosol continuously comes out of the exhalation side of the T-piece. When oxygen flow rates are adequate through the humidifier, a mist or aerosol should continuously be seen from the exhalation port both during inhalation and exhalation. The exhalation port should be kept open and uncovered; draping it might occlude the airway. The T-piece does not touch the skin so it does not need to be padded. An oral suctioning device should never be used to suction the T-piece because it is contaminated with oral flora and will introduce infection.

What is recommended as safe nursing practice when caring for a client with a tracheostomy and T-piece? 1 Ensure that aerosol continuously comes out of the exhalation side of the T-piece. 2 When working in close proximity to the exhalation port, the nurse should drape it. 3 The T-piece should be padded to protect the skin. 4 Use the oral suctioning device to clear secretions from the T-piece.

2 Ensure that oxygen bubbles through the water in the humidifier. When the oxygen flow rate is greater than 4 L/min, humidification should be used to prevent drying of the nasal mucosa. The nurse should ensure that there is adequate water in the humidifier chamber and that oxygen is bubbling through it. The nasal cannula should be cleaned as needed, but does not require routine cleaning. Measurement of oxygen saturation using pulse oximetry should be done at intervals and does not need to be monitored continuously. Elevating the head of the bed 45 degrees is not necessary when administering nasal O2.

When administering oxygen to a client at 5 L/min per nasal cannula, which intervention does the nurse include in the client's plan of care? 1 Clean the nasal cannula every 4 hours. 2 Ensure that oxygen bubbles through the water in the humidifier. 3 Continuously monitor O2 saturation with a pulse oximeter. 4 Elevate the head of the bed 45 degrees.

2 Partial pressure of arterial oxygen (Pao2) Pao2 is a measure of the amount of oxygen in the arterial blood. Fio2 is a measure of the inspired oxygen, which may not all be absorbed. PEEP is a measure of positive expiratory pressure for a client on a ventilator. CPAP is a delivery system, not a measure of oxygenation.

When assessing the adequacy of a client's oxygenation, which information is important for the nurse to note? 1 Fraction of inspired oxygen (Fio2) 2 Partial pressure of arterial oxygen (Pao2) 3 Positive end-expiratory pressure (PEEP) 4 The client's acceptance of the continuous positive airway pressure (CPAP) machine.

2 Encourage ambulation and out-of-bed activities 4 Use a sponge tooth cleaner or soft toothbrush moistened in water for oral hygiene. Ambulation and increased activity promote lung expansion, gas exchange, and removal of secretions. These are desirable outcomes for the client with an artificial airway. The recommended best practice to clean and protect oral mucosa is to use water and a soft toothbrush or sponge tooth cleaner. Lemon glycerin swabs have a drying effect on oral mucosa and change the normal pH, contributing to bacterial overgrowth. Hydrogen peroxide may damage healthy tissue and is not routinely recommended. It requires a prescription by the health care provider. The client should be turned and repositioned every 1-2 hours.

When planning the care of a client with a tracheostomy, which interventions does the nurse include? Select all that apply. 1 Use lemon glycerin swabs to provide oral hygiene. 2 Encourage ambulation and out-of-bed activities. 3 If the client is bedbound, turn and reposition every 4-6 hours. 4 Use a sponge tooth cleaner or soft toothbrush moistened in water for oral hygiene. 5 Mix equal parts of hydrogen peroxide and water to use as a mouthwash.

3 The pilot balloon should be inflated. A cuffed tube is used during mechanical ventilation; so the pilot balloon should remain inflated, indicating the cuff is inflated. A cuffed tube does not guarantee that aspiration will not occur. Most newly placed tubes utilize a disposable inner cannula, which is replaced during tracheostomy care. Test-Taking Tip: Do not read information into questions, and avoid speculating. Reading into questions creates errors in judgment.

When providing care to a client with a recently placed tracheostomy who is on a mechanical ventilator, which principle guides nursing care? 1 A noncuffed tracheostomy tube is usually used in this situation. 2 A cuffed tube protects against aspiration. 3 The pilot balloon should be inflated. 4 The inner cannula will be removed, cleaned, and reused during tracheostomy care.

1 Oxygen saturation by pulse oximetry is less than 90%. Oxygen saturation below 90% indicates hypoxemia and is a reason to stop suctioning. The cough reflex is an expected response to suctioning; it does not preclude the necessity to clear the airway, although excessive coughing would prompt the nurse to allow the client to rest. The suction catheter can be irrigated to empty thick secretions and restore suction. An increased heart rate from 72 to 78 is not substantial to cause concern. Test-Taking Tip: Do not spend too much time on one question, because it can compromise your overall performance. There is no deduction for incorrect answers, so you are not penalized for guessing. You cannot leave an answer blank; therefore, guess. Go for it! Remember: You do not have to get all the questions correct to pass.

When providing suctioning through an endotracheal or tracheostomy tube, what alerts the nurse to stop suctioning? 1 Oxygen saturation by pulse oximetry is less than 90%. 2 The client coughs uncontrollably during suctioning. 3 Secretions are thick and occluding the suction catheter. 4 The client's heart rate increases from 72 to 78.

2 Preoxygenating the client with 100% oxygen for 30 seconds to 3 minutes before suctioning 4 When suctioning, using a gentle twirling motion of the catheter 6 If needed, repeating suctioning up to three passes Preoxygenation is a proactive strategy to diminish suction-related hypoxemia. The technique of suctioning using a gentle twirling motion diminishes the risk of mucosal injury. No more than three suctioning passes are recommended to minimize hypoxemia, tissue hypoxia, and related complications. The recommended negative pressure for suction is 80-120 mm Hg. Suction should not be applied during catheter insertion, but rather only during removal. The rule is not to suction more than 10-15 seconds to prevent hypoxia and complications.

When suctioning a tracheostomy or endotracheal tube, what nursing actions ensure safe and effective practice? Select all that apply. 1 Adjusting the pressure dial on the suction source to 120-160 mm Hg 2 Preoxygenating the client with 100% oxygen for 30 seconds to 3 minutes before suctioning 3 Applying suction while quickly inserting the catheter and slowly removing it 4 When suctioning, using a gentle twirling motion of the catheter 5 Not suctioning longer than 20 seconds 6 If needed, repeating suctioning up to three passes

3 Administer 100% oxygen by bag-valve-mask.

Which action does the nurse take if a client develops bradycardia during nasopharyngeal suctioning? 1 Administer a bronchodilator using a small particle nebulizer. 2 Ask the client to hold the breath and then cough. 3 Administer 100% oxygen by bag-valve-mask. 4 Complete the suctioning as quickly as possible.

3 Securing new ties before removing the old ones Keeping the tube in place to prevent accidental decannulation is critical. Old ties or Velcro should be kept in place until the new ones are secure. Cleaning the stoma, replacing the disposable cannula, and assessing for skin breakdown are important, but maintaining the placement of the tube is the priority. Test-Taking Tip: What happens if you find yourself in a slump over the examination? Take a time-out to refocus and reenergize! Talk to friends and family who support your efforts in achieving one of your major accomplishments in life. This effort will help you regain confidence in yourself and get you back on track toward the realization of your long-anticipated goal.

Which action is a priority safety precaution when performing tracheostomy care? 1 Cleaning the stoma with half-strength hydrogen peroxide 2 Replacing the disposable cannula 3 Securing new ties before removing the old ones 4 Assessing for skin breakdown

2 Noisy respirations 4 Dyspnea 5 Difficulty inserting a suction catheter Noisy respirations are heard when secretions accumulate and obstruct air flow in the tube. Dyspnea will occur if the airway is obstructed. Dried secretions may make it difficult to pass a suction catheter through the tube. Asymmetry of chest movement does not indicate an obstructed airway. If the tracheostomy is obstructed, tachypnea would result, not bradypnea. Edema around the stoma is external to the tracheostomy tube and would not obstruct the tube.

Which assessment findings may indicate a tracheostomy tube is obstructed? Select all that apply. 1 Asymmetrical chest movement 2 Noisy respirations 3 Bradypnea 4 Dyspnea 5 Difficulty inserting a suction catheter 6 Edema around the stoma

1 Liquid oxygen is available in lightweight, easy-to-carry containers. 3 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 client must be cautioned about open flames in the home, but a family member who smokes should not preclude a client's access to home oxygen. Oxygen in the home will not harm children if proper precautions are taken.

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

3 Chronic hypercarbia Clients with chronic hypercarbia need lower levels of oxygen delivery since a low Pao2 level is this client's primary stimulus for breathing. High-flow oxygen delivery will cause oxygen-induced hypoventilation and CO2 narcosis. Clients with any level of hypoxia should have oxygen flow levels of 2-4 L/min. Clients with acute hypercarbia may have high-flow oxygen without a risk of oxygen-induced hypoventilation. Study Tip: Develop a realistic plan of study. Do not set rigid, unrealistic goals.

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

1 Absorptive atelectasis Collapsed alveoli cause atelectasis (called absorptive atelectasis), which is detected as crackles and decreased breath sounds on auscultation. The manifestations of oxygen toxicity are the same as those for acute respiratory distress syndrome. Oxygen induced hypoventilation is related to carbon dioxide retention. Collapsed alveoli is not the cause of pneumonia. Study Tip: A helpful method for decreasing test stress is to practice self-affirmation. After you have adequately studied and really know the material, start looking in the mirror each time you pass one and say to yourself—preferably out loud—"I know this material, and I will do well on the test." After several times of watching and hearing yourself reaffirm your knowledge, you will gain inner confidence and be able to perform much better during the test period. This technique really works for students who are adventurous enough to use it. It may feel silly at first, but if it works, who cares? It will work for performing skills in clinical as well, as long as you have practiced the skill sufficiently.

Which of the following conditions is caused by collapsed alveoli? 1 Absorptive atelectasis 2 Acute respiratory distress syndrome 3 Pneumonia 4 Oxygen induced hypoventilation

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 client 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.

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

2 Using scarves and other approaches for covering the tracheostomy site 4 Having the client use a mirror to view the appearance of the tracheostomy A tracheostomy is a significant change in appearance and body image. Nurses can facilitate adjustment to this change by encouraging the client to view the site early and by providing information for ways to cover the site without interfering with oxygenation. The spread of infection is a safety concern, not a psychosocial one. Teaching about oxygen equipment does not address a psychosocial issue. Oxygen levels should be monitored; however, this is for safety rather than psychosocial concerns.

Which relevant psychosocial issues should the nurse address with a client who has a new tracheostomy? Select all that apply. 1 Preventing the spread of infection when the client coughs out sputum 2 Using scarves and other approaches for covering the tracheostomy site 3 Teaching about the equipment available for oxygen use at home 4 Having the client use a mirror to view the appearance of the tracheostomy 5 Monitoring the client's oxygenation levels for significant changes