EXAM 3 CH 21

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The nurse is caring for a client being weaned from a mechanical ventilator. Which findings would require the weaning process to be terminated?

blood pressure increases 20 mmHg from baseline In collaboration with the primary provider, the nurse would terminate the weaning process if adverse reactions occur, including a *heart rate increase of 20 beats/min, systolic blood pressure increase of 20 mm Hg, a decrease in oxygen saturation to less than 90%, respiratory rate less than 8 or greater than 20 breaths/min, ventricular dysrhythmias, fatigue, panic, cyanosis, erratic or labored breathing, and paradoxical chest movement*. A vital capacity of 10 to 15 mL/kg, maximum inspiratory pressure (MIP) at least -20 cm H2O, tidal volume of 7 to -9 mL/kg, minute ventilation of 6 L/min, and a rapid/shallow breathing index below 100 breaths/min/L; PaO2 greater than 60 mm Hg with FiO2 less than 40% are criteria that indicate a client is ready to be weaned from the ventilator. A normal vital capacity is 10 to 15 mL/kg.

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" "count to 3" "exhale through pursed lips" "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.

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? Select all that apply.

1. Substernal pain 2. Dyspnea 3. Fatigue Oxygen toxicity can occur when clients receive too high a concentration of oxygen for an extended period. Symptoms include dyspnea, substernal pain, restlessness, fatigue, and progressive respiratory difficulty. Bradycardia and mood swings are not symptoms of oxygen toxicity.

Which of the following ranges of water pressure identifies the amount of pressure within the endotracheal tube cuff that is believed to prevent both injury and aspiration?

15-20

The nurse is assigned the care of a patient with a chest tube. The nurse should ensure that which of the following items is kept at the patient's bedside?

A bottle of sterile water

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 Anemic hypoxia is a result of decreased effective hemoglobin concentration, which causes a decrease in the oxygen-carrying capacity of the blood. It is rarely accompanied by hypoxemia. Carbon monoxide poisoning, because it reduces the oxygen-carrying capacity of hemoglobin, produces similar effects but is not strictly anemic hypoxia, because hemoglobin levels may be normal.

Which of the following is a potential complication of a low pressure in the ET cuff?

Aspiration pneumonia

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 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 decresed effectiveness of coughing with a tracheostomy tube. Again, this is not a viable option.

For a client with an endotracheal (ET) tube, which nursing action is the most important?

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.

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 Criteria for terminating the weaning process include heart rate increase of 20 beats/min and systolic blood pressure increase of 20 mm Hg. A normal vital capacity is 10 to 15 mL/kg.

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.

The nurse is caring for a patient with an endotracheal tube (ET). Which of the following nursing interventions is contraindicated?

Deflating the cuff routinely 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.

After suctioning a tracheostomy tube, the nurse assesses the client to determine the effectiveness of the suctioning. Which findings indicate that the airway is now patent?

Effective breathing at a rate of 16 breaths/minute through the established airway

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

Kinking of the ventilator tubing Explanation: 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.

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 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.

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. Because oxygen supports combustion, there is always a danger of fire when it is used. It is important to post "No Smoking" signs when oxygen is in use, particularly in facilities that are not smoke free.

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 For a new tracheostomy, two people should assist with tie changes. The other actions, if performed by the nurse during tracheostomy care, are correct.

The nurse is teaching the client in respiratory distress ways to prolong exhalation to improve respiratory status. The nurse tells the client to

Purse the lips when exhaling air from the lungs. Explanation: To prolong exhalation, the client may perform breathing while sitting in a chair or walking. The client is to inhale through the nose and then exhale against pursed lips. There is no holding the breath.

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 (Ventolin) before performing postural drainage. When a client is to perform postural drainage, the nurse should instruct the client to use the prescribed bronchodilator (e.g., albuterol) first. This will open airways and promote drainage. The client is to perform postural drainage before meals, not after. This will aid in preventing nausea, vomiting, and aspiration. For secretions accumulated in the upper lobes, the client will sit up or even lean forward while sitting. Head on a pillow is not a sufficient increase in height. The client is also to lay in each position for 10 to 15 minutes.

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. 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 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. Explanation: ET suctioning removes oxygen, lowering the partial pressure of arterial oxygen; this, in turn, may induce a cardiac arrhythmia. Hyperventilating and hyperoxygenating the client before and during (or after) suctioning helps prevent this complication. Subcutaneous emphysema occurs when air from the pleural cavity leaks into subcutaneous tissue; it isn't a complication associated with suctioning. Hyperventilation and hyperoxygenation can't prevent a pneumothorax because this condition itself indicates air in the pleural space. Pulmonary edema is associated with cardiac dysfunction, not ET suctioning.

A patient is being mechanically ventilated in the ICU. The ventilator alarms begin to sound. The nurse should complete which of the following actions first?

Troubleshoot to identify the malfunction. The nurse should first immediately attempt to identify and correct the problem and, if the problem cannot be identified and/or corrected, the patient must be manually ventilated with an Ambu bag. The respiratory therapist may be notified, but this is not the first action by the nurse. The nurse should not reposition the ET tube as a first response to an alarm.

Which of the following is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means

Venturi mask

Which of the following is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means?

Venturi mask

Which type of ventilator has a present volume of air to be delivered with each inspiration?

Volume-controlled With volume-controlled ventilation, the volume of air to be delivered with each inspiration is present. 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 present pressure, and then cycles off, and expiration occurs passively.

Intermittent mandatory ventilation (IMV) provides

a combination of mechanically assisted breaths and spontaneous breaths

Constant bubbling in the water seal of a chest drainage system indicates which of the following problems?

air leak

SIMV

delivers a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the client can breathe spontaneously with no assistance from the ventilator for those extra breaths. Pressure support ventilation assists SIMV by applying a pressure plateau to the airway throughout the client-triggered inspiration to decrease resistance within the tracheal tube and ventilator tubing.

A nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is:

keeping his airway patent. Explanation: Maintaining a patent airway is the most basic and critical human need. Helping the client communicate, encouraging him to perform ADLs, and preventing him from developing an infection are important to the client's well-being but not as important as having sufficient oxygen to breathe.

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?

neg pressure ventilator This client needs ventilatory support. His PaO2 is low despite receiving a high dose of oxygen. The iron lung or drinker respiratory tank is an example of a negative-pressure ventilator. This type of ventilator is used mainly with chronic respiratory failure associated with neurological disorders, such as muscular dystrophy. It does not require intubation of the client. The most common ventilator is the positive-pressure ventilator, but this involves intubation with an endotracheal tube or tracheostomy. CPAP is used for obstructive sleep apnea. Bi-PAP is used for those with severe COPD or sleep apnea who require ventilatory assistance at night.

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 In general, the nurse should apply suction no longer than 10. Applying suction for longer is hazardous and may result in the development of hypoxia, which can lead to dysrhythmias and, ultimately, cardiac arrest. Applying suction for 0-5 seconds would provide too little time for effective suctioning of secretions.

A client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which oxygen delivery method would give the greatest level of inspired oxygen?

nonrebreather mask A nonrebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask, face tent, and nasal cannula — deliver lower levels of FIO2.

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. To prevent tracheal dilation, a minimal-leak technique should be used and the pressure should be kept at less than 25 cm H2O. Suctioning is vital but won't prevent tracheal dilation. Use of a cuffed tube alone won't prevent tracheal dilation. The tracheostomy shouldn't be plugged to prevent tracheal dilation. This technique is used when weaning the client from tracheal support.

Fluctuations in the ______ are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respiration

water-seal compartment

Which of the following are indicators that a client is ready to be weaned from a ventilator? Select all that apply.

• PaO2 of 64 mm Hg • Tidal volume of 8.5 mL/kg • Vital capacity of 13 mL/kg Weaning criteria for clients are as follows: Vital capacity 10 to 15 mL/kg; Maximum inspiratory pressure at least -20 cm H2; Tidal volume: 7 to 9 mL/kg; Minute ventilation: 6 L/min; Rapid/shallow breathing index below 100 breaths/min; PaO2 > 60 mm Hg; FiO2 < 40%

The nurse should monitor and document the amount and character of drainage every 2 hours. The nurse will notify the primary provider if drainage is _____ or greater.

50 mL/hr

Which of the following would indicate a decrease in pressure with mechanical ventilation?

increase in compliance

A male adult client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism? A. Dyspnea B. Bradypnea C. Bradycardia D. Decreased respirations

A. Dyspnea Explanation: The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain.

Arterial blood gases should be obtained at which timeframe following the initiation of continuous mechanical ventilation?

20 min

The nurse is caring for a patient following a thoracotomy. Which of the following findings requires immediate intervention by the nurse?

Chest tube drainage of 190 mL/hr The nurse should monitor and document the amount and character of drainage every 2 hours. The nurse will notify the primary provider if drainage is 150 mL/hr or greater. The other findings are normal following a thoracotomy; no intervention is required.

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

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 preparing to perform chest physiotherapy (CPT) on a patient. Which of the following patient statements would indicate the procedure is contraindicated. a) "I received my pain medication 10 minutes ago, let's do my CPT now." b) "I just finished eating my lunch, I'm ready for my CPT now." c) "I just changed into my running suit; we can do my CPT now." d) "I have been coughing all morning and am barely bringing anything up."

"I just finished eating my lunch, I'm ready for my CPT now." When performing CPT, the nurse ensures that the patient is comfortable, is not wearing restrictive clothing, and has not just eaten. The nurse gives medication for pain, as prescribed, before percussion and vibration and splints any incision and provides pillows for support, as needed. A goal of CPT is for the patient to be able to mobilize secretions; the patient who is having an unproductive cough is a candidate for CPT.

A client has been placed on a ventilator, and the spouse is visiting for the first time. The spouse begins to cry. The best statement by the nurse is

"Tell me what you are feeling."

A client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. He's placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. The nursing goal should be to reduce the FIO2 to no greater than:

0.5. An FIO2 greater than 0.5 for as little as 16 to 24 hours can be toxic and can lead to decreased gas diffusion and surfactant activity. The ideal oxygen source is room air FIO2 0.21.

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.)

1. Hold the breath at the end of inspiration for a few seconds. 2. Cough frequently. 3. 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.

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.

1. Monitor pulmonary status as directed and needed. 2. Regularly assess the client's vital signs every 2 to 4 hours. 3. Encourage deep breathing exercises. Interventions to improve the client's gas exchange include monitoring pulmonary status as directed and needed, assessing vital signs every 2 to 4 hours, and encouraging deep breathing exercises. Maintainin an open airway is appropriate for improving the client's airway clearance. Monitoring and recording hourly intake and output are essential interventions for ensuring appropriate fluid balance.

The nurse is teaching a client the proper technique for diaphragmatic breathing. Place the steps for this procedure in the correct sequence.

1. Place one hand on the abdomen and the other hand on the middle of the chest to increase awareness of the position of the diaphragm and its function in breathing. 2. Breathe in slowly and deeply through the nose, letting the abdomen protrude as far as possible. 3. Breathe out through pursed lips while tightening the abdominal muscles. 4. Press firmly inward and upward on the abdomen while breathing out. 5. Repeat for 1 minute; follow with a 2-minute rest period. The correct sequence for diaphragmatic breathing is as follows: (1) Place one hand on the abdomen (just below the ribs) and the other hand on the middle of the chest to increase awareness of the position of the diaphragm and its function in breathing. (2) Breathe in slowly and deeply through the nose, letting the abdomen protrude as far as possible. (3) Breathe out through pursed lips while tightening (contracting) the abdominal muscles. (4) Press firmly inward and upward on the abdomen while breathing out. (5) Repeat for 1 minute; follow with a 2-minute rest period.

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.

1. Tracheal ischemia 2. Tracheal bleeding 3. Pressure necrosis Complications can occur from pressure exerted by the cuff on the tracheal wall. Cuff pressures should be maintained between 20 and 25 mm Hg. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis, whereas low cuff pressure can increase the risk of aspiration pneumonia. Routine deflation of the cuff is not recommended because of the increased risk of aspiration and hypoxia.

Which of the following is a correct endotracheal tube cuff pressure?

17mmhg

The nurse is caring for a patient in the ICU who required emergent endotracheal (ET) intubation with mechanical ventilation. The nurse receives an order to obtain arterial blood gases (ABGs) following the procedure. The nurse recognizes that ABGs should be obtained at which timeframe following the initiation of mechanical ventilation?

20 minutes

Arterial blood gases should be obtained how often after initiating continuous mechanical ventilation?

20 minutes ABGs should be obtained to measure carbon dioxide partial pressure (PaCO2), pH, and PaO2 after 20 minutes of continuous mechanical ventilation.

Which is a correct endotracheal tube cuff pressure?

22 mm Hg Cuff pressures should be checked with a calibrated aneroid manometer device every 6 to 8 hours to maintain cuff pressures between 20 and 25 mm Hg. The other values are not within the normal range for adequate cuff pressure.

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:

5 to 20 minutes. Initially, the nurse should plug the opening in the tracheostomy tube for 5 to 20 minutes, then gradually lengthen this interval according to the client's respiratory status. A client who doesn't require continuous mechanical ventilation already is breathing without assistance, at least for short periods; therefore, plugging the opening of the tube for only 15 to 60 seconds wouldn't be long enough to reveal the client's true tolerance to the procedure. Plugging the opening for more than 20 minutes would increase the risk of acute respiratory distress because the client requires an adjustment period to start breathing normally.

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 It is essential that the nurse ensure that a bottle of sterile water is readily available at the client's bedside. If the chest tube and drainage system become disconnected, air can enter the pleural space, producing a pneumothorax. To prevent the development of a pneumothorax, a temporary water seal can be established by immersing the open end of the chest tube in a bottle of sterile water. There is no need to have an Ambu bag, incentive spirometer, or a set of hemostats at the bedside.

A patient 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?

A lung volume reduction Explanation: Lung volume reduction is a surgical procedure involving the removal of 20%-30% of a patient's lung through a midsternal incision or video thoracoscopy. The diseased lung tissue is identified on a lung perfusion scan. This surgery leads to significant improvements in dyspnea, exercise capacity, quality of life, and survival of a subgroup of people with end-stage emphysema (Oey, Morgan, Spyt, et al., 2010).

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?

A lung volume reduction Lung volume reduction is a surgical procedure involving the removal of 20%-30% of a client's lung through a midsternal incision or video thoracoscopy. The diseased lung tissue is identified on a lung perfusion scan. This surgery leads to significant improvements in dyspnea, exercise capacity, quality of life, and survival of a subgroup of people with end-stage emphysema.

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 Partial rebreathing masks have a reservoir bag that must remain inflated during both inspiration and expiration. The nurse adjusts the oxygen flow to ensure that the bag does not collapse during inhalation. A high concentration of oxygen (50% to 75%) can be delivered because both the mask and the bag serve as reservoirs for oxygen. The other devices listed cannot deliver oxygen at such a high concentration.

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?

"When the tube is being removed, take a deep breath, exhale, and bear down" When assisting in removal of a chest tube, instruct the client to perform a gentle Valsalva maneuver 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.

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. The client has bled 120 mL of bloody drainage in the chest drainage system within 15 minutes. It is most important for the nurse to assess for signs and symptoms of hemorrhage, which may be indicated by a rapid pulse and decreasing blood pressure. The nurse may then lay the client in a flat position and notify the physician.

A male patient's X-ray result reveals bilateral white-outs, indicating adult respiratory distress syndrome (ARDS). This syndrome results from: A. Cardiogenic pulmonary edema B. Respiratory alkalosis C. Increased pulmonary capillary permeability D. Renal failure

C. Increased pulmonary capillary permeability Explanation: ARDS results from increased pulmonary capillary permeability, which leads to noncardiogenic pulmonary edema. In cardiogenic pulmonary edema, pulmonary congestion occurs secondary to heart failure. In the initial stage of ARDS, respiratory alkalosis may arise secondary to hyperventilation; however, it does not cause ARDS. Renal failure does not cause ARDS, either.

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

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.

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?

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.

A nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority?

Assessing the client's respiratory status, orientation, and skin color Explanation: A nonrebreather mask can deliver high concentrations of oxygen to the client in acute respiratory distress. Assessment of a client's status is a priority for determining the effectiveness of therapy. There is no need for the nurse to post a "No smoking" sign over the client's bed. Smoking is a fire hazard and is prohibited in hospitals regardless of whether the client is receiving oxygen from a nonrebreather mask. Oil-based lubricants can cause pneumonia by promoting bacteria growth. Equipment should be changed daily, but this is a lower priority than assessing respiratory status, orientation, and skin color.

A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs?

Auscultation Explanation: 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.

Which of the following is an adverse reaction that would require termination of the weaning process from the ventilator?

Blood pressure increase of 20 mm Hg

A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client? a) By suctioning the client frequently b) By placing the call button under the client's pillow c) By supplying a magic slate or similar device d) By providing a tracheostomy plug to use for verbal communication

By supplying a magic slate or similar device The nurse should use a nonverbal communication method, such as a magic slate, note pad and pencil, and picture boards (if the client can't write or speak English). The physician orders a tracheostomy plug when a client is being weaned off a tracheostomy; it doesn't enable the client to communicate. The call button, which should be within reach at all times for all clients, can summon attention but doesn't communicate additional information. Suctioning clears the airway but doesn't enable the client to communicate.

Air leak Correct Explanation: The nurse needs to observe for air leaks in the drainage system; they are indicated by constant bubbling in the water seal chamber, or by the air leak indicator in dry systems with a one-way valve. Tidaling is fluctuation of the water level in the water seal that shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent.

Constant bubbling in the water seal of a chest drainage system indicates which of the following problems? a) Tension pneumothorax b) Air leak c) Increased drainage d) Tidaling

A patient is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this patient?

Continuous positive airway pressure Continuous positive airway pressure (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. To use CPAP, the patient must be breathing independently.

What treatment modality will be the most effective for this patient? Continuous positive airway pressure Surgery to remove the tonsils and adenoids Bi-level positive airway pressure Medications to assist the patient with sleep at night

The nurse is transporting a patient with chest tubes to a treatment room. The chest tube becomes disconnected and falls between the bed rail. What is the priority action by the nurse? a) Immediately reconnect the chest tube to the drainage apparatus. b) Cut the contaminated tip of the tube and insert a sterile connector and reattach. c) Clamp the chest tube close to the connection site. d) Call the physician.

Cut the contaminated tip of the tube and insert a sterile connector and reattach. If the patient is lying on a stretcher and must be transported to another area, place the drainage system below the chest level. If the tubing disconnects, cut off the contaminated tips of the chest tube and tubing, insert a sterile connector in the cut ends, and reattach to the drainage system. Do not clamp the chest tube during transport. (less)

Nurse Ruth assessing a patient for tracheal displacement should know that the trachea will deviate toward the: A. Contralateral side in a simple pneumothorax B. Affected side in a hemothorax C. Affected side in a tension pneumothorax D. Contralateral side in hemothorax

D. Contralateral side in hemothorax Explanation: The trachea will shift according to the pressure gradients within the thoracic cavity. In tension pneumothorax and hemothorax, accumulation of air or fluid causes a shift away from the injured side. If there is no significant air or fluid accumulation, the trachea will not shift. Tracheal deviation toward the contralateral side in simple pneumothorax is seen when the thoracic contents shift in response to the release of normal thoracic pressure gradients on the injured side.

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

Every 2 to 4 hours Continuous positive-pressure ventilation increases the production of secretions regardless of the patient's underlying condition. The nurse assesses for the presence of secretions by lung auscultation at least every 2 to 4 hours.

The nurse is preparing to perform chest physiotherapy (CPT) on a patient. Which of the following patient statements would indicate the procedure is contraindicated.

I just finished eating my lunch, I'm ready for my CPT now."

A nurse is caring for a client after a thoracotomy for a lung mass. Which nursing diagnosis should be the first priority?

Impaired gas exchange

A nurse is attempting to wean a client after 2 days on the mechanical ventilator. The client has an endotracheal tube present with the cuff inflated to 15 mm Hg. The nurse has suctioned the client with return of small amounts of thin white mucus. Lung sounds are clear. Oxygen saturation levels are 91%. What is the priority nursing diagnosis for this client?

Impaired gas exchange related to ventilator setting adjustments

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 tube 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.

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

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 patient has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the patient 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 Explanation: 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, 2010). 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.

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

Reduced cardiac output PEEP reduces cardiac output by increasing intrathoracic pressure and reducing the amount of blood delivered to the left side of the heart. It doesn't affect heart rate, but a decrease in cardiac output may reduce blood pressure, commonly causing compensatory tachycardia, not bradycardia. However, the resulting tachycardia isn't a direct effect of PEEP therapy itself.

Which of the following statements would not be considered an appropriate intervention for a patient with an ET tube?

Routine cuff deflation is recommended Routine cuff deflation is not recommended because of the increased risk for aspiration and hypoxia. The cuff is deflated before the endotracheal tube is removed. Cuff pressures should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tube.

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

Routinely deflating the cuff Explanation: 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 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. A high-pressure alarm on a continuous mechanical ventilator indicates an obstruction in the flow of oxygen 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 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 chlorhexadine daily The five key elements of the VAP bundle include *elevation of the head of the bed (30 to 45 degrees [semi-Fowler's position)], daily "sedation vacations," and assessment of readiness to extubate; peptic ulcer disease prophylaxis (with histamine-2 receptor antagonists); deep venous thrombosis prophylaxis; and daily oral care with chlorhexidine (0.12% oral rinses)*. The client should be turned and repositioned every 2 hours to prevent complications of immobility and atelectasis and to optimize lung expansion.

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

cleaning the pts mouth with chlorhexidine daily

A client with end-stage chronic obstructive pulmonary disease (COPD) requires bi-level positive airway pressure (BiPAP). While caring for the client, the nurse determines that bilateral wrist restraints are required to prevent compromised care. Which client care outcome is associated with restraint use in the client who requires BiPAP?

The client will maintain adequate oxygenation. BiPAP is a type of continuous positive airway pressure in which both inspiratory and expiratory pressures are set above atmospheric pressure. This type of ventilatory support assists clients with COPD who retain PaCO2. Restraints are necessary in this client to maintain BiPAP therapy if the client attempts to dislodge the mask despite instruction not to do so. Maintaining oxygenation is the expected outcome in this client. Remaining infection- and pain-free and maintaining adequate urine output aren't direct outcomes of the client who requires BiPAP and needs restraints to maintain his safety.

Which statements would be considered appropriate interventions for a client with an endotracheal tube? Select all that apply.

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. The cuff is deflated before the endotracheal tube is removed. Cuff pressures should be checked every 6 to 8 hours. And must be maintained at 15- 2 mm Hg to prevent excess pressure , High cuff pressure leads to tracheal bleeding and other complications. Humidified oxygen should always be introduced through the tube. Routine cuff deflation is not recommended because of the increased risk for aspiration and hypoxia. It is recommended to provide oral hygiene and suction the oropharynx whenever necessary, the cough , glottic, pharyngeal ,and laryngeal reflexes are suppressed and the nurse needs to keep all airways clear for the client.

Which type of ventilator has a pre-sent volume of air to be delivered with each inspiration?

Volume cycled With volume-cycled ventilation, the volume of air to be delivered with each inspiration is present. 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 present pressure, and then cycles off, and expiration occurs passively.

Which type of ventilator has a preset volume of air to be delivered with each inspiration?

Volume-controlled Explanation: 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.

client has a sucking stab wound to the chest. Which action should the nurse take first?

apply a dressing and tape down 3 sides

Which of the following is a potential complication of a low pressure in the endotracheal tube (ET) cuff?

aspiration pneumonia

Which of the following ventilator modes 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? Select all that apply.

before meals bedtime The nurse should perform chest physiotherapy at bedtime to reduce secretions in the client's lungs during the night. It is important to perform chest physiotherapy before meals to prevent nausea, vomiting, and aspiration. Percussion and vibration, components of chest physiotherapy, may worsen bronchospasms; therefore, the procedure is contraindicated in clients with bronchospasms. Secretions that have mobilized (especially when suction equipment isn't available) are a contraindication for postural drainage, another component of chest physiotherapy.

Which of the following is an adverse reaction that would require termination of the weaning process from the ventilator? PaOgreater than 60 mmHg with a FiO less than 40% Heart rate less than 100 B blood pressure increase of 20 mm Hg Vital capacity of 12 mL/kg

blood pressure increase of 20 mm Hg Criteria for termination of the weaning process includes: heart rate increase of 20 beats per minute, and systolic blood pressure increase of 20 mm Hg. A normal vital capacity is 10 to 15 mL/kg.

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. The nurse should instruct the client to cough during cuff deflation. If the client can't cough, the nurse should perform suctioning to prevent aspiration of secretions. Because the cuff should be deflated during expiration, the client shouldn't take a deep breath as the nurse deflates the cuff. Likewise, because the cuff is reinflated during inspiration, the client shouldn't hold the breath or exhale deeply during reinflation.

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 approximately at least 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.

Assist-control ventilation provides

full ventilator support by delivering a preset tidal volume and respiratory rate.

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

gastrointestinal hemorrhage Gastrointestinal hemorrhage occurs in approximately 25% of clients receiving prolonged mechanical ventilation. Other possible complications include incorrect ventilation, oxygen toxicity, fluid imbalance, decreased cardiac output, pneumothorax, infection, and atelectasis. Immunosuppression and pulmonary emboli are not direct consequences of mechanical ventilation.

A client who underwent thoracic surgery to remove a lung tumor had a chest tube placed anteriorly. The surgical team places this catheter to

remove air from the pleural space .After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand. A catheter placed in the pleural space provides a drainage route through a closed or underwater-seal drainage system to remove air. Sometimes two chest catheters are placed following thoracic surgery: one anteriorly and one posteriorly. The anterior catheter removes air; the posterior catheter removes fluid.

The nurse is caring for a patient following a wedge resection. While the nurse is assessing the patient's chest tube drainage system, constant bubbling is noted in the water seal chamber. This finding indicates which of the following problems?

Air leak

Air leak The nurse needs to observe for air leaks in the drainage system; they are indicated by constant bubbling in the water seal chamber, or by the air leak indicator in dry systems with a one-way valve. Tidaling is fluctuation of the water level in the water seal that shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent.

The nurse is caring for a client following a wedge resection. While the nurse is assessing the client's chest tube drainage system, constant bubbling is noted in the water seal chamber. This finding indicates which problem?

Air leak Explanation: The nurse needs to observe for air leaks in the drainage system; they are indicated by constant bubbling in the water seal chamber, or by the air leak indicator in dry systems with a one-way valve. Tidaling is fluctuation of the water level in the water seal that shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent.

19. Which of the following would be most appropriate for a male client with an arterial blood gas (ABG) of pH 7.5, PaCO2 26 mm Hg, O2 saturation 96%, HCO3 24 mEq/L, and PaO2 94 mm Hg? a. Administer a prescribed decongestant. b. Instruct the client to breathe into a paper bag. c. Offer the client fluids frequently. d. Administer prescribed supplemental oxygen.

19. Answer B. The ABG results reveal respiratory alkalosis. The best intervention to raise the PaCO2 level would be to have the client breathe into a paper bag. All of the other options — such as administering a decongestant, offering fluids frequently, and administering supplemental oxygen — wouldn't raise the lowered PaCO2 level.

Which of the following would be most appropriate for a male client with an arterial blood gas (ABG) of pH 7.5, PaCO2 of 26 mm Hg, O2 saturation level of 96%, HCO3 of 24 mEq/L, and PaO2 of 94%? A. Administer a prescribed decongestant B. Instruct the client to breathe into a paper bag C. Offer the client fluids frequently D. Administer prescribed supplemental oxygen

D. Administer prescribed supplemental oxygen Explanation: The ABG results reveal respiratory alkalosis. The best intervention to raise the PaCO2 level would be to have the client breathe into a paper bag. All of the other options-such as administer a prescribed decongestant, offer the client fluids frequently, or administer prescribed supplemental oxygen would do nothing to raise the PaCO2 level.

At 11 p.m., a male client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He's anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-medrol) I.V. At 11:30 p.m., the client's arterial blood oxygen saturation is 86% and he's still wheezing. The nurse should plan to administer: A. Alprazolam (Xanax) B. Propranolol (Inderal) C. Morphine D. Albuterol (Proventil)

D. Albuterol (Proventil) Explanation: The client is hypoxemic because of bronchoconstriction as evidenced by wheezes and a subnormal arterial oxygen saturation level. The client's greatest need is bronchodilation, which can be accomplished by administering bronchodilators. Albuterol is a beta2 adrenergic agonist, which causes dilation of the bronchioles. It's given by nebulization or metered-dose inhalation and may be given as often as every 30 to 60 minutes until relief is accomplished. Alprazolam is an anxiolytic and central nervous system depressant, which could suppress the client's breathing. Propranolol is contraindicated in a client who's wheezing because it's a beta2 adrenergic antagonist. Morphine is a respiratory center depressant and is contraindicated in this situation.

An emergency room nurse is assessing a male client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client? A. A low respiratory rate B. Diminished breath sounds C. The presence of a barrel chest D. A sucking sound at the site of injury

Explanation: B. Diminished breath sounds This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.

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 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.

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 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.)

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

intermediate mandatory ventilation (IMV) IMV provides a combination of mechanically assisted breaths and spontaneous breaths. Assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate. SIMV delivers a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the client can breathe spontaneously with no assistance from the ventilator for those extra breaths. Pressure support ventilation assists SIMV by applying a pressure plateau to the airway throughout the client-triggered inspiration to decrease resistance within the tracheal tube and ventilator tubing.

A client has a sucking stab wound to the chest. Which action should the nurse take first?

apply a dressing over the wound and tape it on three sides The nurse should immediately apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line.

Which is a potential complication of a low pressure in the endotracheal tube cuff?

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.

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

assist control Assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate. IMV provides a combination of mechanically assisted breaths and spontaneous breaths. SIMV delivers a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the patient can breathe spontaneously with no assistance from the ventilator for those extra breaths. Pressure support ventilation assists SIMV by applying a pressure plateau to the airway throughout the client-triggered inspiration to decrease resistance within the tracheal tube and ventilator tubing.

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 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.

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

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.

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 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.

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 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.

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 When caring for a client who's recovering from a thoracotomy, the nurse should encourage coughing and deep breathing to prevent pneumonia. Fluctuations in the water-seal chamber are normal. Clamping the chest tube could cause a tension pneumothorax. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage.

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 The client is encouraged to cough frequently to mobilize secretions. The client will be placed in the semi-Fowler's position. The chest tube is always attached to closed, sealed drainage to re-expand lung tissue and prevent pneumothorax. Restricting IV fluids in a client who is NPO while recovering from surgery would lead to dehydration.

A client is postoperative and prescribed an incentive spirometer (IS). The nurse instructs the client to:

expect coughing when using the spirometer properly When using an incentive spirometer, the client should be sitting or in the semi-Fowler's position. The client is to inhale, hold the breath for about 3 seconds, and then exhale slowly. Coughing occurs with the use of the incentive spirometer and is encouraged. The client should use the spirometer 10 times every hour while awake.

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

hyperbaric Hyperbaric oxygen therapy is the administration of oxygen at pressures greater than atmospheric pressure. As a result, the amount of oxygen dissolved in plasma is increased, which increases oxygen levels in the tissues. Low-flow systems contribute partially to the inspired gas the client breathes, which means that the client breathes some room air along with the oxygen. High-flow systems are indicated for clients who require a constant and precise amount of oxygen. During transtracheal oxygenation, clients achieve adequate oxygenation at lower rates, making this method less expensive and more efficient.

The nurse is educating a patient with COPD about the technique for performing pursed-lip breathing. What does the nurse inform the patient is the importance of using this technique?

it prolongs exhalation The goal of pursed-lip breathing is to prolong exhalation and increase airway pressure during expiration, thus reducing the amount of trapped air and the amount of airway resistance.

kinking over 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 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 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.

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) 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

A nurse is caring for a client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do?

place the end of the chest tube in a container of sterile saline If a chest drainage system is disconnected, the nurse may place the end of the chest tube in a container of sterile saline or water to prevent air from entering the chest tube, thereby preventing negative respiratory pressure. The nurse should apply an occlusive dressing if the chest tube is pulled out — not if the system is disconnected. The nurse shouldn't clamp the chest tube because clamping increases the risk of tension pneumothorax. The nurse should tape the chest tube securely to prevent it from being disconnected, rather than taping it after it has been disconnected.

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 nursing unit with two chest tubes The nurse should plan for the client to return to the nursing unit with two chest tubes intact. During a lobectomy, the lobe is removed, and the remaining lobes of the lung are re-expanded. Usually, two chest catheters are inserted for drainage. The upper tube is for air removal; the lower one is for fluid drainage. Sometimes only one catheter is needed. The chest tube is connected to a chest drainage apparatus for several days.

The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for:

symmetry of the client's chest expansion Immediately after intubation, the nurse should check for symmetry of chest expansion. This is one finding that indicates successful endotracheal placement. The tracheal cuff pressure is set between 15 and 20 mm Hg. Routine deflation of the tracheal cuff is not recommended, because the client could then aspirate secretions during the period of deflation. Warm, high, humidified air is administered through the endotracheal tube.

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

venturi mask The Venturi mask is the most reliable and accurate method for delivering precise concentrations of oxygen way that allows a constant flow of room air blended with a fixed flow of oxygen. It is used primarily for patients with COPD because it can accurately provide appropriate levels of supplemental oxygen, thus avoiding the risk of suppressing the hypoxic drive.

Which is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means?

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.

10. On arrival at the intensive care unit, a critically ill female client suffers respiratory arrest and is placed on mechanical ventilation. The physician orders pulse oximetry to monitor the client's arterial oxygen saturation (SaO2) noninvasively. Which vital sign abnormality may alter pulse oximetry values? a. Fever b. Tachypnea c. Tachycardia d. Hypotension

10. Answer D. Hypotension, hypothermia, and vasoconstriction may alter pulse oximetry values by reducing arterial blood flow. Likewise, movement of the finger to which the oximeter is applied may interfere with interpretation of SaO2. All of these conditions limit the usefulness of pulse oximetry. Fever, tachypnea, and tachycardia don't affect pulse oximetry values directly.

A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct?

"before you do the exercise, I will 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.

14. A male client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. He's placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. The nursing goal should be to reduce the FIO2 to no greater than: a. 0.21 b. 0.35 c. 0.5 d. 0.7

14. Answer C. An FO2 greater than 0.5 for as little as 16 to 24 hours can be toxic and can lead to decreased gas diffusion and surfactant activity. The ideal oxygen source is room air F IO 2 0.18 to 0.21.

The nurse is assigned the care of a patient with a chest tube. The nurse should ensure that which of the following items is kept at the patient's bedside? a) An incentive spirometer b) A bottle of sterile water c) A set of hemostats d) An Ambu bag

A bottle of sterile water It is essential that the nurse ensure that a bottle of sterile water is readily available at the patient's bedside. If the chest tube and drainage system become disconnected, air can enter the pleural space, producing a pneumothorax. To prevent the development of a pneumothorax, a temporary water seal can be established by immersing the chest tube's open end in a bottle of sterile water. There is no need to have an Ambu bag, incentive spirometer, or a set of hemostats at the bedside.

Constant bubbling in the water seal of a chest drainage system indicates which of the following problems? Tidaling Increased drainage Air leak Tension pneumothorax

Air leak

A male patient has a sucking stab wound to the chest. Which action should the nurse take first? A. Drawing blood for a hematocrit and hemoglobin level B. Applying a dressing over the wound and taping it on three sides C. Preparing a chest tube insertion tray D. Preparing to start an I.V. line

B. Applying a dressing over the wound and taping it on three sides Explanation: The nurse immediately should apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line.

A nurse is caring for a male client with acute respiratory distress syndrome. Which of the following would the nurse expect to note in the client? A. Pallor B. Low arterial PaO2 C. Elevated arterial PaO2 D. Decreased respiratory rate

B. Low arterial PaO2 Explanation: The earliest clinical sign of acute respiratory distress syndrome is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a PaO2 lower than 60 mm Hg.

After undergoing a left pneumonectomy, a female patient has a chest tube in place for drainage. When caring for this patient, the nurse must:

C. Encourage coughing and deep breathing Explanation: When caring for a patient who is recovering from a pneumonectomy, the nurse should encourage coughing and deep breathing to prevent pneumonia in the unaffected lung. Because the lung has been removed, the water-seal chamber should display no fluctuations. Reinflation is not the purpose of chest tube. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage.

Nurse Oliver observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? A. The system is functioning normally B. The client has a pneumothorax C. The system has an air leak D. The chest tube is obstructed

C. The system has an air leak Explanation: Constant bubbling in the 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 nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.

A patient with a recent history of a dry cough has had a chest x-ray that revealed the presence of nodules. In an effort to determine whether the nodules are malignant or benign, what is the primary care provider likely to order? A Thoracentesis B Pulmonary angiogram C CT scan of the patient's chest D Positron emission tomography (PET)

D Rationale: PET is used to distinguish benign and malignant pulmonary nodules. Because malignant lung cells have an increased uptake of glucose, the PET scan (which uses an IV radioactive glucose preparation) can demonstrate increased uptake of glucose in malignant lung cells. This differentiation cannot be made using CT, a pulmonary angiogram, or thoracentesis.

A male adult patient hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? A. Nausea or vomiting B. Abdominal pain or diarrhea C. Hallucinations or tinnitus D. Lightheadedness or paresthesia

D. Lightheadedness or paresthesia Explanation: The patient with respiratory alkalosis may complain of lightheadedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rare are associated with respiratory alkalosis or any other acid-base imbalance.

After suctioning a tracheostomy tube, the nurse assesses the client to determine the effectiveness of the suctioning. Which findings indicate that the airway is now patent? a) Effective breathing at a rate of 16 breaths/minute through the established airway b) Increased pulse rate, rapid respirations, and cyanosis of the skin and nail beds c) Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds d) A respiratory rate of 28 breaths/minute with accessory muscle use

Effective breathing at a rate of 16 breaths/minute through the established airway Proper suctioning should produce a patent airway, as demonstrated by effective breathing through the airway at a normal respiratory rate of 12 to 20 breaths/minute. The other options suggest ineffective suctioning. A respiratory rate of 28 breaths/minute and accessory muscle use may indicate mild respiratory distress. Increased pulse rate, rapid respirations, and cyanosis are signs of hypoxia. Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds indicate respiratory secretion accumulation.

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 Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.

The nurse is caring for a patient who is scheduled to have a thoracotomy. When planning preoperative teaching, what information should the nurse communicate to the patient? a) How to splint the incision when coughing b) How to take prophylactic antibiotics correctly c) How to milk the chest tubing d) How to manage the need for fluid restriction

How to splint the incision when coughing Prior to thoracotomy, the nurse educates the patient about how to splint the incision with the hands, a pillow, or a folded towel. The patient is not taught how to milk the chest tubing because this is performed by the nurse. Prophylactic antibiotics are not normally used and fluid restriction is not indicated following thoracotomy.

A nurse is caring for a client after a thoracotomy for a lung mass. Which nursing diagnosis should be the first priority? a) Anxiety b) Deficient knowledge: Home care c) Impaired physical mobility d) Impaired gas exchange

Impaired gas exchange Impaired gas exchange should be the nurse's first priority. After ensuring that the client has adequate gas exchange, she can address the other diagnoses of Anxiety, Impaired physical mobility, and Deficient knowledge: Home Care.

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 Hypoxemic hypoxia, or hypoxemia, is a decreased oxygen level in the blood (PaO2) resulting in decreased oxygen diffusion into the tissues.

The nurse is discussing activity management with a patient who is postoperative following thoracotomy. What instructions should the nurse give to the patient regarding activity immediately following discharge? a) Walk on a treadmill 30 minutes daily. b) Perform shoulder exercises five times daily. c) Walk 1 mile 3 to 4 times a week. d) Use weights daily to increase arm strength.

Perform shoulder exercises five times daily. The nurse emphasizes the importance of progressively increased activity. The nurse also instructs the patient on the importance of performing shoulder exercises five times daily. The patient should ambulate with limits and realize that the return of strength will likely be gradual and likely will not include weight lifting or lengthy walks.

A nurse is educating a patient in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the patient and the family that this drainage system is used for? a) Removing excess air and fluid b) Monitoring pleural fluid osmolarity c) Maintaining positive chest-wall pressure d) Providing positive intrathoracic pressure

Removing excess air and fluid Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. They are not used to maintain positive chest-wall pressure, monitor pleural fluid, or provide positive intrathoracic pressure

A nurse is weaning a client from mechanical ventilation. Which assessment finding indicates the weaning process should be stopped?

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. Although the client's blood pressure has increased, it hasn't increased more than 20% over baseline, which would indicate that the client isn't tolerating the weaning process.

While caring for a patient with an endotracheal tube, the nurses recognizes that suctioning is required how often? a) When the nurse needs to stimulate the cough reflex b) Every 2 hours when the patient is awake c) When there is a need to prevent the patient from coughing d) When adventitious breath sounds are auscultated

When adventitious breath sounds are auscultated 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 present. Unnecessary suctioning, such as scheduling every 2 hours, can initiate bronchospasm and cause trauma to the tracheal mucosa.

In general, chest drainage tubes are not used for the patient undergoing

pneumonectomy. Usually, no drains are used for the pneumonectomy patient because the accumulation of fluid in the empty hemothorax prevents mediastinal shift. With lobectomy, two chest tubes are usually inserted for drainage, the upper tube for air and the lower tube for fluid. With wedge resection, the pleural cavity usually is drained because of the possibility of an air or blood leak. With segmentectomy, drains are usually used because of the possibility of an air or blood leak.

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 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.

A nurse educator is reviewing the indications for chest drainage systems with a group of medical nurses. What indications should the nurses identify? Select all that apply. a) Chest trauma resulting in pneumothorax b) Need for postural drainage c) Post thoracotomy d) Pleurisy e) Spontaneous pneumothorax

• Post thoracotomy • Spontaneous pneumothorax • Chest trauma resulting in pneumothorax Chest drainage systems are used in treatment of spontaneous pneumothorax and trauma resulting in pneumothorax. Postural drainage and pleurisy are not criteria for use of a chest drainage system.

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? (Select all that apply.)

Sustains positive end expiratory pressure (PEEP) Decreases hypoxemia Decreases patient anxiety An in-line suction device allows the patient to be suctioned without being disconnected from the ventilator circuit. In-line suctioning (also called closed suctioning) decreases hypoxemia, sustains PEEP, and can decrease patient anxiety associated with suctioning (Sole et al., 2013).

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 should monitor and document the amount and character of drainage *every 2 hours*. The nurse must notify the primary provider if drainage is *≥150 mL/hr*. The other findings are normal following a thoracotomy and no intervention would be required.

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) 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 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 my lunch, I am 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 client has been placed on a ventilator, and the spouse begins to cry during the initial visit. What is the best therapeutic statement for the nurse to communicate?

"tell me what you are feeling" The best option is to have the spouse verbalize feelings. The other statements are not therapeutic because teaching should not be done while the spouse is crying. People on a ventilator may experience pain. The best treatment statement minimizes what the spouse is experiencing and does not encourage communication.

13. The amount of air inspired and expired with each breath is called: a. tidal volume. b. residual volume. c. vital capacity. d. dead-space volume.

13. Answer A. Tidal volume is the amount of air inspired and expired with each breath. Residual volume is the amount of air remaining in the lungs after forcibly exhaling. Vital capacity is the maximum amount of air that can be moved out of the lungs after maximal inspiration and expiration. Dead-space volume is the amount of air remaining in the upper airways that never reaches the alveoli. In pathologic conditions, dead space may also exist in the lower airways.

The OR nurse is setting up a water-seal chest drainage system for a patient who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system? a) 20 cm H2O b) 5 cm H2O c) 15 cm H2O d) 10 cm H2O

20 cm H2O The amount of suction is determined by the water level. It is usually set at 20 cm H2O; adding more fluid results in more suction.

22. For a male client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the plan of care? a. Measuring and documenting the drainage in the collection chamber b. Maintaining continuous bubbling in the water-seal chamber c. Keeping the collection chamber at chest level d. Stripping the chest tube every hour

22. Answer A. The nurse should measure and document the amount of chest tube drainage regularly 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 should not strip chest tubes because doing so may traumatize the tissue or dislodge the tube.

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 mmHg 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 of the following is a potential complication of a low pressure in the ET cuff? Pressure necrosis Tracheal ischemia Tracheal bleeding Aspiration pneumonia

Aspiration pneumonia Low pressure in the cuff can increase the risk for aspiration pneumonia. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis.

You are admitting a patient with complaints of abdominal pain, nausea, and vomiting. A bowel obstruction is suspected. You assess this patient for which anticipated primary acid-base imbalance if the obstruction is high in the intestine? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

B. Metabolic alkalosis Because gastric secretions are rich in hydrochloric acid, the patient who is vomiting will lose a significant amount of gastric acid and be at an increased risk for metabolic alkalosis.

You are caring for a patient admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) who has the following arterial blood gas results: pH 7.33, PaO2 47 mm Hg, PaCO2 60 mm Hg, HCO3 32 mEq/L, and O2 saturation of 92%. What is the correct interpretation of these results? A. Fully compensated respiratory alkalosis B. Partially compensated respiratory acidosis C. Normal acid-base balance with hypoxemia D. Normal acid-base balance with hypercapnia

B. Partially compensated respiratory acidosis A low pH (normal 7.35-7.45) indicates acidosis. In the patient with respiratory disease such as COPD, the patient retains carbon dioxide (normal 35-45 mm Hg), which acts as an acid in the body. For this reason, the patient has respiratory acidosis. The elevated HCO3 indicates a partial compensation for the elevated CO2.

Which phrase is used to describe the volume of air inspired and expired with a normal breath? A. Total lung capacity B. Forced vital capacity C. Tidal volume D. Residual volume

C. Tidal volume Explanation: Tidal volume refers to the volume of air inspired and expired with a normal breath. Total lung capacity is the maximal amount of air the lungs and respiratory passages can hold after a forced inspiration. Forced vital capacity is the vital capacity performed with a maximally forced expiration. Residual volume is the maximal amount of air left in the lung after a maximal expiration.

A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? A. pH, 5.0; PaCO2 30 mm Hg B. pH, 7.40; PaCO2 35 mm Hg C. pH, 7.35; PaCO2 40 mm Hg D. pH, 7.25; PaCO2 50 mm Hg

D. pH, 7.25; PaCO2 50 mm Hg Explanation: In respiratory acidosis, ABG analysis reveals an arterial pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg. Therefore, the combination of a pH value of 7.25 and a PaCO2 value of 50 mm Hg confirms respiratory acidosis. A pH value of 5.0 with a PaCO2 value of 30 mm Hg indicates respiratory alkalosis. Options B and C represent normal ABG values, reflecting normal gas exchange in the lungs.

The nurse is assessing a patient who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the patient's respirations. How should the nurse best respond to this assessment finding? a) Document that the chest drainage system is operating as it is intended. b) Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes. c) Inform the physician promptly that there is in imminent leak in the drainage system. d) Encourage the patient to do deep breathing and coughing exercises.

Document that the chest drainage system is operating as it is intended. Fluctuation of the water level in the water seal shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent. No further action is needed.

Before seeing a newly assigned female client with respiratory alkalosis, the nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis?

Extreme anxiety Extreme anxiety may lead to respiratory alkalosis by causing hyperventilation, which results in excessive carbon dioxide (CO2) loss. Other conditions that may set the stage for respiratory alkalosis include fever, heart failure, and injury to the brain's respiratory center, overventilation with a mechanical ventilator, pulmonary embolism, and early salicylate intoxication. Type 1 diabetes mellitus may lead to diabetic ketoacidosis; the deep, rapid respirations occurring in this disorder (Kussmaul's respirations) don't cause excessive CO2 loss. Myasthenia gravis and narcotic overdose suppress the respiratory drive, causing CO2 retention, not CO2 loss; this may lead to respiratory acidosis, not alkalosis.

Which of the following would indicate a decrease in pressure with mechanical ventilation? Plugged airway tube Kinked tubing Increase in compliance Decrease in lung compliance

Increase in compliance

A nurse has performed tracheal suctioning on a patient who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention? a) Percuss the patient's lungs and thorax. b) Determine whether the patient can now perform forced expiratory technique (FET). c) Measure the patient's oxygen saturation. d) Have the patient perform incentive spirometry.

Measure the patient's oxygen saturation. The patient's response to suctioning is usually determined by performing chest auscultation and by measuring the patient's oxygen saturation. FET, incentive spirometry, and percussion are not normally used as evaluative techniques.

The nurse is caring for a patient who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. What method of oxygen delivery is most appropriate for the patient's needs? a) Simple mask b) Nasal cannula c) Partial-rebreathing mask d) Non-rebreathing mask

Nasal cannula A nasal cannula is used when the patient requires a low to medium concentration of oxygen for which precise accuracy is not essential. The Venturi mask is used primarily for patients with COPD because it can accurately provide an appropriate level of supplemental oxygen, thus avoiding the risk of suppressing the hypoxic drive. The patient's respiratory status does not require a partial- or non-rebreathing mask.

A client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery is most likely to reverse these manifestations?

Nonrebreather mask A nonrebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask, face tent, and nasal cannula — deliver lower levels of FIO2.

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. Observe for air leaks in the drainage system; they are indicated by constant bubbling in the water seal chamber, or by the air leak indicator in dry systems with a one-way valve. In addition, assess the chest tube system for correctable external leaks. Notify the primary provider immediately of excessive bubbling in the water seal chamber not due to external leaks.

A patient is being mechanically ventilated with an oral endotracheal tube in place. The nurse observes that the cuff pressure is 25 mm Hg. The nurse is aware of what complications that can be caused by this pressure? (Select all that apply.)

Pressure necrosis Tracheal bleeding Tracheal aspiration Complications can occur from pressure exerted by the cuff on the tracheal wall. Cuff pressures should be maintained between 15 and 20 mm Hg (Morton, Fontaine, Hudak, et al., 2009). High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis, whereas low cuff pressure can increase the risk of aspiration pneumonia. Routine deflation of the cuff is not recommended because of the increased risk of aspiration and hypoxia.

The client is postoperative for a total laryngectomy and has recovered from anesthesia. The client's respirations are 32 breaths/minute, blood pressure is 102/58, and pulse rate is 104 beats/minute. Pulse oximetry is 90%. The client is receiving humidified oxygen. To aid in the client's respiratory status, the nurse places the client in which of the following positions.

Semi- Fowler's The client is in respiratory distress. The best position for the client who has a tracheostomy and recovered from anesthesia is semi-Fowler's.

The nurse is teaching a postoperative client who had a coronary artery bypass graft about using the incentive spirometer. T

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 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 from the cuff, and reinflate it. After discovering an air leak, the nurse first should check for insufficient air in the cuff — the most common cause of a cuff air leak. To do this, the nurse should suction the client, withdraw all residual air from the cuff, and then reinflate the cuff to prevent overinflation and possible cuff rupture. The nurse should notify the physician only after determining that the air leak can't be corrected by nursing interventions, or if the client develops acute respiratory distress. The tracheostomy tube cuff can't be removed and replaced with a new one without changing the tracheostomy tube; also, removing the cuff would create a total air leak, which isn't correctable. Adding more air to the cuff without first removing residual air may cause cuff rupture.

A client is being mechanically ventilated in the ICU. The ventilator alarms begin to sound. The nurse should complete which action first?

troubleshoot to identify the malfunction The nurse should first immediately attempt to identify and correct the problem; if the problem cannot be identified and/or corrected, the client must be manually ventilated with an Ambu bag. The respiratory therapist may be notified, but this is not the first action by the nurse. The nurse should not reposition the endotracheal tube as a first response to an alarm.

Which of the following is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means? Partial-rebreathing mask Venturi mask T-piece Nasal cannula

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.

Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. This therapy may be used for a client with:

a compromised skin graft A client with a compromised skin graft could benefit from hyperbaric oxygen therapy because increasing oxygenation at the wound site promotes wound healing. Hyperbaric oxygen therapy isn't indicated for malignant tumors, pneumonia, or hyperthermia.

A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for

a kink in the ventilator tubing One event that could cause the ventilator's peak-airway-pressure alarm to sound is a kink in the ventilator tubing. After making this and other assessments without correction, then it could be a malfunction of the alarm button. Higher than normal endotracheal cuff pressure could cause client tissue damage but would not make the ventilator alarms sound. A cut or slice in the tubing from the ventilator would result in decreased pressure.

A nurse is planning care for a client after a tracheostomy. One of the client's goals is to overcome verbal communication impairment. Which intervention should the nurse include in the care plan?

encourage the client's communication attempts by allowing him time to select or write words The nurse should allow ample time for the client to respond and shouldn't speak for him. She should use as many aids as possible to assist the client with communicating and encourage the client when he attempts to communicate. When the client is ready, the nurse can use a tracheostomy plug to facilitate speech. Making an effort to read the client's lips and answering questions for the client are inappropriate.

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 mandatoruy ventilation (SIMV) In SIMV mode, the ventilator delivers a preset number of breaths at a preset tidal volume. The client can breathe on his own in between the breaths delivered by the ventilator. In PSV, a pressure plateau is added to the ventilator to prevent the airway pressure from falling beneath a preset level. In AC ventilation, the ventilator delivers a preset number of breaths at a preset tidal volume and any breaths that the client takes on his own are assisted by the ventilator so they reach the preset tidal volume. In CPAP, the ventilator provides only positive airway pressure; it doesn't provide any breaths to the client.

A patient is to receive an oxygen concentration of 70%. What is the best way for the nurse to deliver this concentration? a) A Venturi mask b) An oropharyngeal catheter c) A partial rebreathing mask d) A nasal cannula

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 Before weaning the client from mechanical ventilation, it's most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins.

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? Select all that apply.

• To provide adequate transport of oxygen in the blood • To reduce stress on the myocardium • To decrease the work of breathing Oxygen therapy is designed to provide adequate transport of oxygen in the blood while decreasing the work of breathing and reducing stress on the myocardium. Incentive spirometry is a respiratory modality that provides visual feedback to encourage the client to inhale slowly and deeply to maximize lung inflation and prevent or reduce atelectasis. A mini-nebulizer is used to help clear secretions

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