347 Ch 21 prep u resp care modalities
A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned?
auscultate the lung for adventitious sounds
For a client with an endotracheal (ET) tube, which nursing action is the most important ?
auscultating the lungs for bilateral breath sounds
After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must:
encourage coughing and deep breathing
A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?
kinking of the ventilator tubing
which oxygen administration devices device has the advantage of providing a high concentration?
nonbreathing mask
the nurse is caring for a client with an endotracheal tube (ET) which nursing intervention is contraindicated?
routinely deflating the cuff
a client with myasthenia gravis is receiving continuous mechanical ventilation. when the high pressure alarm on the ventilator sounds, what should the nurse do?
suction the clients artificial airway
A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?
the system has an air leak
A client in acute respiratory distress is brought to the emergency department. After endotracheal (ET) intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the ET tube, the nurse hyperventilates
they help prevent cardiac arrhythmias
which is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means?
venturi mask
which type of ventilator has a preset volume of air to be delivered with each inspiration?
volume cycled
After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes? Collection chamber Air-leak chamber Water-seal chamber Suction control chamber
water seal chamber
A nurse is caring for a client with COPD who needs teaching on pursed-lip breathing. Place the steps in order in which the nurse will instruct the client.
Inhale through your nose." "Slowly count to 3." "Exhale slowly through pursed lips." "Slowly count to 7."
A client who is undergoing thoracic surgery has a nursing diagnosis of "Impaired gas exchange related to lung impairment and surgery" on the nursing care plan. Which of the following nursing interventions would be appropriately aligned with this nursing diagnosis? Select all that apply
Monitor pulmonary status as directed and needed. Regularly assess the client's vital signs every 2 to 4 hours. Encourage deep breathing exercises.
a client has a sucking stab wound to the chest. which action should the nurse take first
apply a dresssing over the wound and tape it on 3 sides
what is a potential complication of a low pressure in the endotracheal tube cuff
aspiration pneumonia
what assessment method would the nurse use to determine the areas of the lungs that need draining?
auscultation
A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct?
before you do the exercise, i'll give you pain meds if you need it
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?
partial pressure of arterial oxygen (PaO2)
In general, chest drainage tubes are not indicated for a client undergoing which procedure? Lobectomy Pneumonectomy Segmentectomy Wedge resection
pneumonectomy
A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings?
84 mm Hg
Which is a potential complication of a low pressure in the endotracheal tube cuff? Tracheal ischemia Pressure necrosis Tracheal bleeding Aspiration pneumonia
aspiration pneumonia
a nurse is working with a client being extubated from the ventilator. before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain ?
baseline arterial blood gas (ABG) levels
the nurse is caring for a client following a thoracotomy. which finding requires immediate intervention by the nurse?
chest tube drainage, 190 mL/hr
The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying?
circulatory hypoxia
A client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this client?
continuous positive airway pressure (CPAP)
After suctioning a tracheostomy tube, the nurse assesses the client to determine the effectiveness of the suctioning. which findings indicate that the airway is not patent ?
effective breathing at a rate of 16 bpm through the established airway
A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education?
encourage the patient to take approx 10 breaths per hour, while awake
A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation?
endotracheal suctioning
A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition?
hypoxia
A client has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the client complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect?
oxygen toxicity
The nurse is preparing to perform tracheostomy care for a client with a newly inserted tracheostomy tube. Which action, if performed by the nurse, indicates the need for further review of the procedure?
places clean tracheostomy ties then removed soiled ties after the new ties are in place without a second nurse assisting
The nurse is preparing to perform tracheostomy care for a client with a newly inserted tracheostomy tube. Which action, if performed by the nurse, indicates the need for further review of the procedure?
places clean tracheostomy ties then removes soiled ties after the new ties are in place without a second nurse assisting
the nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient?
the patient is hypoxic from suctioning
A nurse is weaning a client from mechanical ventilation. Which nursing assessment finding indicates the weaning process should be stopped?
runs of ventricular tachycardia
When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for how long?
no longer than 10 seconds
for a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?
measuring and documenting the drainage in the collection chamber
