Ch 21 PrepU

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 medication if you need it."

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

0.5

The nurse received a client from the post-anesthesia care unit (PACU) who has a chest tube to a closed drainage system. Report from the PACU nurse included drainage in the chest tube at 80 mL of bloody fluid. Fifteen minutes after transfer from the PACU, the chest tube indicates drainage as pictured. The client is reporting pain at "8" on a scale of 0 to 10. The first action of the nurse is to:

Assess pulse and blood pressure

A client in the intensive care unit has a tracheostomy with humidified oxygen being instilled through it. The client is expectorating thick yellow mucus through the tracheostomy tube frequently. The nurse

Assesses the client's tracheostomy and lung sounds every 15 minutes

Which ventilator mode provides full ventilatory support by delivering a present tidal volume and respiratory rate?

Assist control

An adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. The ordered respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure?

At bedtime Before meals

Which is an adverse reaction that would require the process of weaning from a ventilator to be terminated?

Blood pressure increase of 20 mm Hg from baseline

A client with supraglottic cancer undergoes a partial laryngectomy. Postoperatively, a cuffed tracheostomy tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to:

Cough as the cuff is being deflated

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.

Which type of oxygen therapy includes the administration of oxygen at pressure greater than atmospheric pressure?

Hyperbaric pressure

The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique?

Instruct the client to remain in each position of the postural drainage sequence for 10-15 minutes

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

Lung volume reduction

The nurse is assessing a patient with chest tubes connected to a drainage system. What should the first action be when the nurse observes excessive bubbling in the water seal chamber?

Notify the physician

A patient is to receive an oxygen concentration of 70%. What is the best way for the nurse to deliver this concentration?

Partial rebreathing mask

Positive end-expiratory pressure (PEEP) therapy has which effect on the heart?

Reduced cardiac output

The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated?

Routinely deflating the cuff

A patient in the ICU has been orally intubated and on mechanical ventilation for 2 weeks after having a severe stroke. What action does the nurse anticipate the physician will take now that the patient has been intubated for this length of time?

The patient will have an insertion of a tracheostomy tube.

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 and hyperoxygenates the client. What is the rationale for these interventions?

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 of the following are indicators that a client is ready to be weaned from a ventilator?

Vital capacity of 13 mL/kg PaO2 of 64 mm Hg Tidal volume of 8.5 mL/kg

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

Anemic hypoxia

Which finding would indicate a decrease in pressure with mechanical ventilation?

Increase in compliance

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

20 minutes

Which is a correct endotracheal tube cuff pressure?

22 mm Hg

Oxygen is a drug, and therefore needs a physician order. Your patient has been ordered to have oxygen at 4 liters per minute per nasal cannula. The nurse know that this flow rate will provide the patient with what percentage of oxygen:

23 - 42% oxygen

A client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for how long

5-20 minutes

A patient with COPD requires oxygen administration. What method of delivery does the nurse know would be best for this patient?

A Venturi mask

The nurse is assigned to care for a client with a chest tube. The nurse should ensure that which item is kept at the client's bedside?

A bottle of sterile water

A patient is to receive an oxygen concentration of 70%. What is the best way for the nurse to deliver this concentration?

A partial rebreathing mask

What assessment method would the nurse use to determine the areas of the lungs that need draining?

Auscultation

The nurse is caring for a client in the ICU who is receiving mechanical ventilation. Which nursing measure is implemented in an effort to reduce the client's risk of developing ventilator-associated pneumonia (VAP)?

Cleaning the client's mouth with chlorhexidine daily

The nurse is using an in-line suction kit to suction a patient who is intubated and on a mechanical ventilator. What benefits does inline suction have for the patient?

Decreases hypoxemia Decreases patient anxiety Sustains positive end expiratory pressure (PEEP)

A client who must begin oxygen therapy asks the nurse why this treatment is necessary? What would the nurse identify as the goals of oxygen therapy?

To decrease the work of breathing To provide adequate transport of oxygen in the blood To reduce stress on the myocardium

A client is recovering from thoracic surgery needed to perform a right lower lobectomy. Which of the following is the most likely postoperative nursing intervention?

Encourage coughing to mobilize secretions.

A client is receiving mechanical ventilation. How frequently should the nurse auscultate the client's lungs to check for secretions?

Every 2-4 hours

The nurse should monitor a client receiving mechanical ventilation for which of the following complications?

Gastrointestinal hemorrhage

The nurse is educating the patient in the use of a mini-nebulizer. What should the nurse encourage the patient to do?

Hold the breath at the end of inspiration for a few seconds Cough frequently Frequently evaluate progress

Which ventilator mode provides a combination of mechanically assisted breaths and spontaneous breaths?

Intermittent mandatory ventilation (IMV)

The nurse is caring for a client who is scheduled for a lobectomy. Following the procedure, the nurse will plan care based on the client

Returning to the unit with two chest tubes.

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?

Monitor pulmonary status as directed and needed Regularly assess the client's vital signs every 2-4 hours Encourage deep breathing exercises

A young male client has muscular dystrophy. His PaO2 is 42 mm Hg with a FiO2 of 80%. Which of the following treatments would be least invasive and most appropriate for this client?

Negative pressure ventilator

Which oxygen administration device has the advantage of providing a high oxygen concentration?

Nonrebreathing mask

A patient with emphysema is placed on continuous oxygen at 2 L/min at home. Why is it important for the nurse to educate the patient and family that they must have No Smoking signs placed on the doors?

Oxygen SUPPORTS combustion

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

A client undergoes a tracheostomy after many failed attempts at weaning him from a mechanical ventilator. Two days after tracheostomy, while the client is being weaned, the nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first?

Suction the client, withdraw residual air rom the cuff, and reinflate it.

The nurse is preparing to perform tracheostomy care for a client with a newly inserted tracheostomy tube. Which action, if preformed 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

In general, chest drainage tubes are not indicated for a client undergoing which procedure?

Pneumonectomy

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?

Pulse oximeter Manual resuscitation bag

A client with COPD has been receiving oxygen therapy for an extended period. What symptoms would be indicators that the client is experiencing oxygen toxicity?

Substernal pain Dyspnea Fatigue

A client is prescribed postural drainage because secretions are accumulating in the upper lobes of the lungs. The nurse instructs the client to:

Take prescribed albuterol before performing postural drainage

Which statements would be considered appropriate interventions for a client with an endotracheal tube?

The cuff is deflated before the tube is removed. Cuff pressures should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tube

A client is being mechanically ventilated with an oral endotracheal tube in place. The nurse observes that the cuff pressure is 28 mm Hg. The nurse is aware of what complications that can be caused by this pressure? Select all that apply.

Tracheal ischemia, Tracheal bleeding, Pressure necrosis

A nurse is caring for a client who has a tracheostomy tube and who is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by:

using the minimal-leak technique with cuff pressure less than 25 cm H2O.

A nurse is caring for a client who was intubated because of respiratory failure. The client is now receiving mechanical ventilation with a preset tidal volume and number of breaths each minute. The client has the ability to breathe spontaneously between the ventilator breaths with no ventilator assistance. The nurse should document the ventilator setting as:

synchronized intermittent mandatory ventilation (SIMV).