Med-Surge Nursing Respiratory Care Prep U ch. 21

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 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 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.

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.

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 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.

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.

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 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.)

1. Decreases hypoxemia 2. Decreases patient anxiety 3. Sustains positive end expiratory pressure (PEEP) 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

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 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.

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

1. Vital capacity of 13 mL/kg 2. Tidal volume of 8.5 mL/kg 3. PaO2 of 64 mm Hg 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%

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

A 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.

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 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 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.

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.

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.

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.

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.

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

Assist control Assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate. Intermittent mandatory ventilation (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 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.

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

At bedtime The nurse should perform chest physiotherapy at bedtime to reduce secretions in the client's lungs during the night. Performing it immediately before a meal may tire the client and impair the ability to eat. 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 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 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.

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

Cleaning the client's mouth with chlorhexidine daily The 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, such as ranitidine [Zantac]); 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.

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.

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.

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?

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.

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 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.

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.

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 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 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 to 15 minutes. Postural drainage is usually performed two to four times daily, before meals (to prevent nausea, vomiting, and aspiration) and at bedtime. Prescribed bronchodilators, water, or saline may be nebulized and inhaled before postural drainage to dilate the bronchioles, reduce bronchospasm, decrease the thickness of mucus and sputum, and combat edema of the bronchial walls. The nurse instructs the client to remain in each position for 10 to 15 minutes and to breathe in slowly through the nose and out slowly through pursed lips to help keep the airways open so that secretions can drain while in each position. If the sputum is foul-smelling, it is important to perform postural drainage in a room away from other patients or family members. (Deodorizers may be used to counteract the odor. Because aerosol sprays can cause bronchospasm and irritation, they should be used sparingly and with caution.)

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

Intermittent 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.

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

Negative-pressure ventilator 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.

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 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 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 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.

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

Pneumonectomy Usually no drains are used in pneumonectomy 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.

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.

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 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.

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

pneumonectomy. Usually no drains are used for a client undergoing pneumonectomy 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 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.

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.

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.