Chapter 21: Respiratory Care Modalities
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? Hypoxic hypoxia Histotoxic hypoxia Anemic hypoxia Circulatory hypoxia
Circulatory hypoxia Given this patient's vital signs, he appears to be in shock. Circulatory hypoxia is hypoxia resulting from inadequate capillary circulation. It may be caused by decreased cardiac output, local vascular obstruction, low-flow states such as shock, or cardiac arrest. Although tissue partial pressure of oxygen (PO2) is reduced, arterial oxygen (PaO2) remains normal. Circulatory hypoxia is corrected by identifying and treating the underlying cause.
A nurse is caring for a client after a thoracotomy for a lung mass. What part of the client's care is the priority for the nurse? Home care Anxiety Impaired mobility Gas exchange
Gas exchange Impaired gas exchange should be the nurse's first priority because of the thoracotomy surgical procedure of opening the client's chest and the client's ability to breathe. After ensuring that the client has adequate gas exchange, the nurse can address anxiety, impaired mobility, and home care.
The nurse is educating the patient in the use of a mini-nebulizer. What should the nurse encourage the patient to do? (Select all that apply.) Hold the breath at the end of inspiration for a few seconds. Take rapid, deep breaths. Cough frequently. Frequently evaluate progress. Prolong the expiratory phase after using the nebulizer.
Hold the breath at the end of inspiration for a few seconds. Cough frequently. Frequently evaluate progress. The nurse instructs the patient to breathe through the mouth, taking slow, deep breaths, and then to hold the breath for a few seconds at the end of inspiration to increase intrapleural pressure and reopen collapsed alveoli, thereby increasing functional residual capacity. The nurse encourages the patient to cough and to monitor the effectiveness of the therapy. The nurse instructs the patient and family about the purpose of the treatment, equipment setup, medication additive, and proper cleaning and storage of the equipment.
The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result? Promote the strengthening of the client's diaphragm Promote the client's ability to take in oxygen Promote more efficient and controlled ventilation and to decrease the work of breathing Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing
Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing Pursed-lip breathing, which improves oxygen transport, helps induce a slow, deep breathing pattern and assists the client to control breathing, even during periods of stress. This type of breathing helps prevent airway collapse secondary to loss of lung elasticity in emphysema.
A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct? "You need to start using the incentive spirometer 2 days after surgery." "Before you do the exercise, I'll give you pain medication if you need it." "Don't use the incentive spirometer more than 5 times every hour." "Breathe in and out quickly."
"Before you do the exercise, I'll give you pain medication if you need it." The nurse should assess the client's pain level before the client does incentive spirometry exercises and administer pain medication as needed. Doing so helps the client take deeper breaths and help prevents atelectasis. The client should breathe in slowly and steadily, and hold his breath for 3 seconds after inhalation. The client should start doing incentive spirometry immediately after surgery and aim to do 10 incentive spirometry breaths every hour.
The nurse is preparing to perform chest physiotherapy (CPT) on a client. Which statement by the client tells the nurse that the procedure is contraindicated. "I just finished eating my lunch, I'm ready for my CPT now." "I just changed into my running suit; we can do my CPT now." "I have been coughing all morning and am barely bringing anything up." "I received my pain medication 10 minutes ago, let's do my CPT now."
"I just finished eating my lunch, I'm ready for my CPT now." When performing CPT, the nurse ensures that the client is comfortable, is not wearing restrictive clothing, and has not just eaten. The nurse gives medication for pain, as prescribed, before percussion and vibration, splints any incision, and provides pillows for support, as needed. A goal of CPT is for the client to be able to mobilize secretions; the client who has an unproductive cough is a candidate for CPT.
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." Pursed-lip breathing is a technique used to prolong exhalation by propping the airways open and promoting the removal of trapped air and carbon dioxide. The nurse should instruct the client to first inhale through the nose to a slow count of 3. Next, the client should exhale slowly through pursed lips for a count of 7.
The nurse is preparing to assist the health care provider to remove a client's chest tube. Which instruction will the nurse correctly give to the client? "While the chest tube is being removed, raise your arms above your head." "Exhale forcefully while the chest tube is being removed." "When the tube is being removed, take a deep breath" "Do not move during the removal of the chest tube because moving will make it more painful."
"When the tube is being removed, take a deep breath" When assisting in the removal of a chest tube, instruct the client to take a deep breath or to breathe quietly. The chest tube is then clamped and quickly removed. Simultaneously, a small bandage is applied and made airtight with petrolatum gauze covered by a 4 × 4-inch gauze pad and thoroughly covered and sealed with nonporous tape. The other options are incorrect instructions for the client.
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? 58 mm Hg 120 mm Hg 45 mm Hg 84 mm Hg
84 mm Hg In general, clients with respiratory conditions are given oxygen therapy only to increase the arterial oxygen pressure (PaO2) back to the client's normal baseline, which may vary from 60 to 95 mm Hg.
Which is a potential complication of a low pressure in the endotracheal tube cuff? Aspiration pneumonia Tracheal ischemia Tracheal bleeding Pressure necrosis
Aspiration pneumonia Low pressure in the cuff can increase the risk for aspiration pneumonia. High pressure in the cuff can cause tracheal bleeding, ischemia, and pressure necrosis.
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 Encourages the client to cough every 30 minutes and prn Sets a schedule to suction the tracheostomy every hour Decreases the amount of humidity set to flow through the tracheostomy tube Assesses the client's tracheostomy and lung sounds every 15 minutes
Assesses the client's tracheostomy and lung sounds every 15 minutes Tracheal suctioning is performed when secretions are obvious or adventitious breath sounds are heard. The client is producing thick yellow mucus frequently, so the nurse needs to make frequent assessments about the need for suctioning. Suctioning every hour could be too frequent or not frequent enough. It also does not address the client's needs. The client needs high humidity to liquify the mucus, which is described as thick. The client has a decreased effectiveness of coughing with a tracheostomy tube. Again, this is not a viable option.
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. Have the patient inform the nurse of the need to be suctioned. Assess the CO2 level to determine if the patient requires suctioning. Have the patient cough.
Auscultate the lung for adventitious sounds. When a tracheostomy or endotracheal tube is in place, it is usually necessary to suction the patient's secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are obviously present. Unnecessary suctioning can initiate bronchospasm and cause mechanical trauma to the tracheal mucosa.
For a client with an endotracheal (ET) tube, which nursing action is the most important? Auscultating the lungs for bilateral breath sounds Monitoring serial blood gas values every 4 hours Providing frequent oral hygiene Turning the client from side to side every 2 hours
Auscultating the lungs for bilateral breath sounds For the client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although turning the client from side to side every 2 hours, monitoring serial blood gas values every 4 hours, and providing frequent oral hygiene are appropriate actions for this client, they're secondary to ensuring adequate oxygenation.
What assessment method would the nurse use to determine the areas of the lungs that need draining? Auscultation Inspection Arterial blood gas (ABG) levels Chest X-ray
Auscultation The nurse should assess breath sounds before doing postural drainage to determine the areas that need draining. Inspection, chest X-rays, and ABG levels are all assessment parameters that give good information about respiratory function but aren't necessary to determine lung areas requiring postural drainage.
A client is prescribed postural drainage because secretions are building in the superior segment of the lower lobes. Which is the best position to teach the client to use for postural drainage?
Certain positions with the head either up or down or lying on one side or the other will promote drainage of secretions from the smaller bronchial airways to the main bronchi and trachea. Think of the anatomy of the lungs when answering this question.
A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse Contacts the respiratory therapy department to report the ventilator is malfunctioning Continues assessing the client's respiratory status frequently Consults with the physician about removing the client from the ventilator Changes the setting on the ventilator to increase breaths to 14 per minute
Continues assessing the client's respiratory status frequently The SIMV setting on a ventilator allows the client to breathe spontaneously with no assistance from the ventilator for those extra breaths. Data in the stem suggest that the ventilator is working correctly. The nurse would continue making frequent respiratory assessments of the client. There are not sufficient data to suggest the client could be removed from the ventilator. There is no reason to increase the ventilator's setting to 14 breaths per minute or to contact respiratory therapy to report the machine is not working properly.
A client is 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) Medications to assist the patient with sleep at night Bi-level positive airway pressure (BiPAP) Surgery to remove the tonsils and adenoids
Continuous positive airway pressure (CPAP) CPAP provides positive pressure to the airways throughout the respiratory cycle. Although it can be used as an adjunct to mechanical ventilation with a cuffed endotracheal tube or tracheostomy tube to open the alveoli, it is also used with a leak-proof mask to keep alveoli open, thereby preventing respiratory failure. CPAP is the most effective treatment for obstructive sleep apnea because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. CPAP is used for clients who can breathe independently. BiPAP is most often used for clients who require ventilatory assistance at night, such as those with severe COPD or sleep apnea.
The nurse hears the patient's ventilator alarm sound and attempts to find the cause. What is the priority action of the nurse when the cause of the alarm is not able to be determined? Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved. Stop the ventilator by pressing the off button, wait 15 seconds, and then turn it on again to see if the alarm stops. Call respiratory therapy and wait until they arrive to determine what is happening. Suction the patient since the patient may be obstructed by secretions.
Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved. If the cause of an alarm cannot be determined, the nurse should disconnect the patient from the ventilator and manually ventilate the patient, because leaving the patient on the mechanical ventilator may be dangerous.
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? Have the patient lie in a supine position during the use of the spirometer. Encourage the patient to take approximately 10 breaths per hour, while awake. Inform the patient that using the spirometer is not necessary if the patient is experiencing pain. Encourage the patient to try to stop coughing during and after using the spirometer.
Encourage the patient to take approximately 10 breaths per hour, while awake. The patient should be instructed to perform the procedure approximately 10 times in succession, repeating the 10 breaths with the spirometer each hour during waking hours. The patient should assume a semi-Fowler's position or an upright position before initiating therapy, not be supine. Coughing during and after each session is encouraged, not discouraged. The patient should Splint the incision when coughing postoperatively. The patient should still use the spirometer when in pain.
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? Delirium Hyperventilation Semiconsciousness Hypoxia
Hypoxia As the respiratory center in the brain becomes depressed, hypoxia occurs, producing wheezing, bradycardia, and a decreased respiratory rate. Delirium is a state of mental confusion characterized by disorientation to time and place. Hyperventilation (respiratory rate greater than that metabolically necessary for gas exchange) is marked by an increased respiratory rate or tidal volume, or both. Semiconsciousness is a state of impaired consciousness characterized by limited motor and verbal responses and decreased orientation.
Which finding would indicate a decrease in pressure with mechanical ventilation? Increase in compliance Kinked tubing Decrease in lung compliance Plugged airway tube
Increase in compliance A decrease in pressure in the mechanical ventilator may be caused by an increase in compliance. Kinked tubing, decreased lung compliance, and a plugged airway tube cause an increase in peak airway pressure.
The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique? Administer bronchodilators and mucolytic agents following the sequence. Perform this measure with the client once a day. Use aerosol sprays to deodorize the client's environment after postural drainage. Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes.
Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes. Postural drainage is usually performed two to four times daily, before meals (to prevent nausea, vomiting, and aspiration) and at bedtime. Prescribed bronchodilators, water, or saline may be nebulized and inhaled before postural drainage to dilate the bronchioles, reduce bronchospasm, decrease the thickness of mucus and sputum, and combat edema of the bronchial walls. The nurse instructs the client to remain in each position for 10 to 15 minutes and to breathe in slowly through the nose and out slowly through pursed lips to help keep the airways open so that secretions can drain while in each position. If the sputum is foul-smelling, it is important to perform postural drainage in a room away from other patients or family members. (Deodorizers may be used to counteract the odor. Because aerosol sprays can cause bronchospasm and irritation, they should be used sparingly and with caution.)
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 A change in the oxygen concentration without resetting the oxygen level alarm A disconnected ventilator circuit An ET cuff leak
Kinking of the ventilator tubing Conditions that trigger the high-pressure alarm include kinking of the ventilator tubing, bronchospasm, pulmonary embolus, mucus plugging, water in the tube, and coughing or biting on the ET tube. The alarm may also be triggered when the client's breathing is out of rhythm with the ventilator. A disconnected ventilator circuit or an ET cuff leak would trigger the low-pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would trigger the oxygen alarm, not the high-pressure alarm.
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? Water-seal chest drainage set-up Tracheostomy cleaning kit Oxygen analyzer Manual resuscitation bag
Manual resuscitation bag The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit at the bedside isn't necessary. Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate the effectiveness of ventilation, this equipment is less important than the manual resuscitation bag.
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? Stripping the chest tube every hour Keeping the collection chamber at chest level Measuring and documenting the drainage in the collection chamber Maintaining continuous bubbling in the water-seal chamber
Measuring and documenting the drainage in the collection chamber The nurse should regularly measure and document the amount of chest tube drainage to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected. The nurse should keep the collection chamber below chest level to allow fluids to drain into it. The nurse shouldn't strip chest tubes because doing so may traumatize the tissue or dislodge the tube.
Which oxygen administration device has the advantage of providing a high oxygen concentration? Face tent Venturi mask Catheter Nonrebreathing mask
Nonrebreathing mask Nonrebreathing masks provide high oxygen concentrations but usually fit poorly. A Venturi mask provides low levels of supplemental oxygen. A catheter is an inexpensive device that provides a variable fraction of inspired oxygen and may cause gastric distention. A face tent provides a fairly accurate fraction of inspired oxygen but is bulky and uncomfortable. It would not be the device of choice to provide a high oxygen concentration.
A client 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-induced hypoventilation Oxygen toxicity Hypoxia Oxygen-induced atelectasis
Oxygen toxicity Oxygen toxicity may occur when too high a concentration of oxygen (greater than 50%) is administered for an extended period (longer than 48 hours) (Urden, Stacy, & Lough, 2014). Signs and symptoms of oxygen toxicity include substernal discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxemia, alveolar atelectasis, and alveolar infiltrates evident on chest x-rays.
The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia? PaO2 HCO3 PCO2 pH
PaO2 Hypoxemic hypoxia, or hypoxemia, is a decreased oxygen level in the blood (PaO2) resulting in decreased oxygen diffusion into the tissues.
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? pH Partial pressure of arterial oxygen (PaO2) Partial pressure of arterial carbon dioxide (PaCO2) Bicarbonate (HCO3-)
Partial pressure of arterial oxygen (PaO2) The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3-, and PaCO2
The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated? Checking the cuff pressure every 6 to 8 hours Deflating the cuff before removing the tube Routinely deflating the cuff Ensuring that humidified oxygen is always introduced through the tube
Routinely deflating the cuff Routine cuff deflation is not recommended because of the increased risk for aspiration and hypoxia. The cuff is deflated before the ET is removed. Cuff pressures should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tube.
A nurse is weaning a client from mechanical ventilation. Which nursing assessment finding indicates the weaning process should be stopped? Runs of ventricular tachycardia Blood pressure remains stable Oxygen saturation of 93% Respiratory rate of 16 breaths/minute
Runs of ventricular tachycardia Ventricular tachycardia indicates that the client isn't tolerating the weaning process. The weaning process should be stopped before lethal ventricular arrhythmias occur. A respiratory rate of 16 breaths/minute and an oxygen saturation of 93% are normal findings. The client's blood pressure remains stable, so the weaning can continue.
The nurse is teaching a postoperative client who had a coronary artery bypass graft about using the incentive spirometer. The nurse instructs the client to perform the exercise in the following order:
Sit in an upright position. Place the mouthpiece of the spirometer in the mouth. Breathe air in through the mouth. Hold breath for about 3 seconds. Exhale air slowly through the mouth. The nurse instructs the client, when using the incentive spirometer, the proper use of it. First, the client is to sit in an upright position. The client is then to place the mouthpiece of the spirometer in the client's mouth. Next, the client breathes air in through the mouth. This causes the incentive spirometer to be activated. The client holds his breath for about 3 seconds. Then, the client exhales slowly through the mouth.
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 client's artificial airway. Ventilate the client with a handheld mechanical ventilator. Check for an apical pulse. Increase the oxygen percentage.
Suction the client's artificial airway. A high-pressure alarm on a continuous mechanical ventilator indicates an obstruction in the flow of gas from the machine to the client. The nurse should suction the client's artificial airway to remove respiratory secretions that could be causing the obstruction. The sounding of a ventilator alarm has no relationship to the apical pulse. Increasing the oxygen percentage and ventilating with a handheld mechanical ventilator wouldn't correct the airflow blockage.
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 in a hypermetabolic state. The patient is having a stress reaction. The patient is hypoxic from suctioning. The patient is having a myocardial infarction.
The patient is hypoxic from suctioning. Apply suction while withdrawing and gently rotating the catheter 360 degrees (no longer than 10-15 seconds). Prolonged suctioning may result in hypoxia and dysrhythmias, leading to cardiac arrest.
A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? The system is functioning normally. The client has a pneumothorax. The system has an air leak. The chest tube is obstructed.
The system has an air leak. Constant bubbling in the water-seal chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the fluid would stop fluctuating in the water-seal chamber.
Which is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means? Nasal cannula Venturi mask T-piece Partial-rebreathing mask
Venturi mask The Venturi mask is the most reliable and accurate method for delivering a precise concentration of oxygen through noninvasive means. The mask is constructed in a way that allows a constant flow of room air blended with a fixed flow of oxygen. Nasal cannula, T-piece, and partial-rebreathing masks are not the most reliable and accurate methods of oxygen administration.
Which type of ventilator has a preset volume of air to be delivered with each inspiration? Negative-pressure Pressure-cycled Volume-controlled Time-cycled
Volume-controlled With volume-controlled ventilation, the volume of air to be delivered with each inspiration is preset. Negative-pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a preset pressure, and then cycles off, and expiration occurs passively.
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? Suction control chamber Collection chamber Water-seal chamber Air-leak chamber
Water-seal chamber Fluctuations in the water-seal compartment are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respirations. The air-leak meter — not chamber — detects air leaking from the pleural space. The collection chamber connects the chest tube from the client to the system. Drainage from the tube drains into and collects in a series of calibrated columns in this chamber. The suction control chamber provides the suction, which can be controlled to provide negative pressure to the chest.