NSG 330 Ch 21- Respiratory Care Modalities

A nurse is caring for a client with COPD who needs teaching on pursed-lip breathing. Place the steps in order in which the nurse will instruct the client.

"Inhale through your nose." "Slowly count to 3." "Exhale slowly through pursed lips." "Slowly count to 7." Explanation: 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 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 Explanation: 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.

What would the critical care nurse recognize as a condition that may indicate a patients need to have a tracheostomy?

A patient requires permanent ventilation. Feedback: A tracheostomy permits long-term use of mechanical ventilation to prevent aspiration of oral and gastric secretions in the unconscious or paralyzed patient. Indications for a tracheostomy do not include a respiratory rate of 10 breaths per minute, symptoms of dyspnea, or respiratory acidosis.

A client on long-term mechanical ventilation becomes very frustrated when he tries to communicate. Which intervention should the nurse perform to assist the client?

Ask the client to write, use a picture board, or spell words with an alphabet board. Explanation: If the client uses an alternative method of communication, such as writing, using a picture board, or spelling words on an alphabet board, he'll feel more in control and be less frustrated. Assuring the client that everything will be all right offers false reassurance and telling him not to be upset minimizes his feelings. Neither of these methods helps the client to communicate. Family members are also likely to encounter difficulty interpreting the wishes of a client with an endotracheal tube or tracheostomy tube. Making them responsible for interpreting the client's gestures may frustrate them. The client may be weaned off a mechanical ventilator only when the physiologic parameters for weaning have been met.

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

Aspiration pneumonia Explanation: 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.

The nurse is preparing to suction a patient with an endotracheal tube. What should be the nurses first step in the suctioning process?

Assess the patients lung sounds and SAO2 via pulse oximeter Assessment data indicate the need for suctioning and allow the nurse to monitor the effect of suction on the patients level of oxygenation. Explaining the procedure would be the second step; performing hand hygiene and don nonsterile gloves, goggles, gown, and mask is the third step, and turning on the suction source at a pressure not exceeding 120 mm Hg is the fourth step.

The nurse is caring for a client with an endotracheal tube who is on a ventilator. When assessing the client, the nurse knows to maintain what cuff pressure to maintain appropriate pressure on the tracheal wall?

Between 15 and 20 mm Hg Complications can occur from pressure exerted by the cuff on the tracheal wall. Cuff pressures should be maintained between 15 and 20 mm Hg.

The physician has ordered continuous positive airway pressure (CPAP) with the delivery of a patients high-flow oxygen therapy. The patient asks the nurse what the benefit of CPAP is. What would be the nurses best response?

CPAP allows a lower percentage of oxygen to be used with a similar effect. Feedback: Prevention of oxygen toxicity is achieved by using oxygen only as prescribed. Often, positive end- expiratory pressure (PEEP) or CPAP is used with oxygen therapy to reverse or prevent microatelectasis, thus allowing a lower percentage of oxygen to be used. Oxygen is moistened by passing through a humidification system. Changing the tubing on the oxygen therapy equipment is the best technique for controlling bacterial growth.

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) Explanation: CPAP provides positive pressure to the airways throughout the respiratory cycle. Although it can be used as an adjunct to mechanical ventilation with a cuffed endotracheal tube or tracheostomy tube to open the alveoli, it is also used with a leak-proof mask to keep alveoli open, thereby preventing respiratory failure. CPAP is the most effective treatment for obstructive sleep apnea because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. CPAP is used for clients who can breathe independently. BiPAP is most often used for clients who require ventilatory assistance at night, such as those with severe COPD or sleep apnea.

The nurse hears the patient's ventilator alarm sound and attempts to find the cause. What is the priority action of the nurse when the cause of the alarm is not able to be determined?

Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved. Explanation: 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.

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient has been receiving high-flow oxygen therapy for an extended time. What symptoms should the nurse anticipate if the patient were experiencing oxygen toxicity?

Dyspnea and substernal pain Feedback: Oxygen toxicity can occur when patients receive too high a concentration of oxygen for an extended period. Symptoms of oxygen toxicity include dyspnea, substernal pain, restlessness, fatigue, and progressive respiratory difficulty. Bradycardia, frontal headache, cyanosis, hypotension, and tachycardia are not symptoms of oxygen toxicity.

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

Expect coughing when using the spirometer properly. Explanation: 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.

A nurse is caring for a client after a thoracotomy for a lung mass. What part of the client's care is the priority for the nurse?

Gas exchange Explanation: Impaired gas exchange should be the nurse's first priority because of the thoracotomy surgical procedure of opening the client's chest and the client's ability to breathe. After ensuring that the client has adequate gas exchange, the nurse can address anxiety, impaired mobility, and home care.

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

Gastrointestinal hemorrhage Explanation: 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.

The nurse is educating the patient in the use of a mini-nebulizer. What should the nurse encourage the patient to do? (Select all that apply.)

Hold the breath at the end of inspiration for a few seconds. Cough frequently. Frequently evaluate progress. Explanation: The nurse instructs the patient to breathe through the mouth, taking slow, deep breaths, and then to hold the breath for a few seconds at the end of inspiration to increase intrapleural pressure and reopen collapsed alveoli, thereby increasing functional residual capacity. The nurse encourages the patient to cough and to monitor the effectiveness of the therapy. The nurse instructs the patient and family about the purpose of the treatment, equipment setup, medication additive, and proper cleaning and storage of the equipment.

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

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. Explanation: 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 performed by the nurse, indicates the need for further review of the procedure?

Places clean tracheostomy ties then removes soiled ties after the new ties are in place without a second nurse assisting Explanation: For a new tracheostomy, two people should assist with tie changes to help make sure the new tracheostomy is not dislodged. A dislodged tracheostomy is a medical emergency. The other actions, if performed by the nurse during tracheostomy care, are correct. The wound and plate should be cleaned with sterile cotton-tipped applicators moistened with saline or sterile water or with hydrogen peroxide if infection is present. The inner cannula should be dried before reinsertion or if a disposable is being used, a new disposable cannula should be reinserted. The nurse should put on clean gloves and discard the soiled dressing in a biohazard container.

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.

The nurse is caring for a patient who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning the patient from a ventilator, the nurse is aware that the weaning of the patient will progress in what order?

Removal from the ventilator, tube, and then oxygen The process of withdrawing the patient from dependence on the ventilator takes place in three stages: the patient is gradually removed from the ventilator, then from the tube, and, finally, oxygen.

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?

Removing excess air and fluid Feedback: 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

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.

The home care nurse is visiting a patient newly discharged home after a lobectomy. What would be most important for the home care nurse to assess?

Signs and symptoms of respiratory complications The nurse assesses the patients adherence to the postoperative treatment plan and identifies acute or late postoperative complications. All options presented need assessment, but respiratory complications are the highest priority because they affect the patients airway and breathing.

The decision has been made to discharge a ventilator-dependent patient home. The nurse is developing a teaching plan for this patient and his family. What would be most important to include in this teaching plan?

Signs of pulmonary infection Feedback: The nurse teaches the patient and family about the ventilator, suctioning, tracheostomy care, signs of pulmonary infection, cuff inflation and deflation, and assessment of vital signs. Neurologic assessment and turning and coughing are less important than signs and symptoms of infection. Inhaled corticosteroids may or may not be prescribed.

The nurse is teaching a postoperative client who had a coronary artery bypass graft about using the incentive spirometer. The nurse instructs the client to perform the exercise in the following order:

Sit in an upright position. Place the mouthpiece of the spirometer in the mouth. Breathe air in through the mouth. Hold breath for about 3 seconds. Exhale air slowly through the mouth. Explanation: 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.

The critical care nurse and the other members of the care team are assessing the patient to see if he is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify?

Stable vital signs and ABGs Among many other predictors, stable vital signs and ABGs are important predictors of successful weaning. Pulse oximetry must greatly exceed 80%. Nutritional status is important, but vital signs and ABGs are even more significant. Patients who are weaned may or may not have full level of consciousness

The home care nurse is assessing a patient who requires home oxygen therapy. What criterion indicates that an oxygen concentrator will best meet the needs of the patient in the home environment?

The patient desires a portable oxygen delivery system that can deliver 2 L/min. Feedback: The use of oxygen concentrators is another means of providing varying amounts of oxygen, especially in the home setting. They can deliver oxygen flows from 1 to 10 L/min and provide an FiO2 of about 40%. They require regular maintenance and are not used for high-flow applications. The patient desiring a portable oxygen delivery system of 2L/min will benefit from the use of an oxygen concentrator.

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.

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 Explanation: 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.

While caring for a patient with an endotracheal tube, the nurses recognizes that suctioning is required how often?

When adventitious breath sounds are auscultated Feedback: It is usually necessary to suction the patients 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.

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

"Before you do the exercise, I'll give you pain medication if you need it." Explanation: 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 the breath for 3 seconds after inhalation. The client should start doing incentive spirometry immediately after surgery and aim to do 10 incentive spirometry breaths every hour.

The nurse is preparing to perform chest physiotherapy (CPT) on a client. Which statement by the client tells the nurse that the procedure is contraindicated.

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

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?

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.

A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings?

84 mm Hg Explanation: 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.

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. Explanation: 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.

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. Explanation: 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 patients plan of care specifies postural drainage. What action should the nurse perform when providing this noninvasive therapy?

Assist the patient into a position that will allow gravity to move secretions. Feedback: Postural drainage is usually performed two to four times per day. The patient uses gravity to facilitate postural draining. The skin should be covered with a cloth or a towel during percussion to protect the skin. Postural drainage is not administered in an upright position or directly following a meal.

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. Explanation: When a tracheostomy or endotracheal tube is in place, it is usually necessary to suction the patient's secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are obviously present. Unnecessary suctioning can initiate bronchospasm and cause mechanical trauma to the tracheal mucosa.

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

Auscultating the lungs for bilateral breath sounds Explanation: For the client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although turning the client from side to side every 2 hours, monitoring serial blood gas values every 4 hours, and providing frequent oral hygiene are appropriate actions for this client, they're secondary to ensuring adequate oxygenation.

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

Auscultation 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.

The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess?

Baseline arterial blood gas (ABG) levels Feedback: Before weaning a patient from mechanical ventilation, it is most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the patient is tolerating the procedure. Other assessment parameters are relevant, but less critical. Measuring fluid volume intake and output is always important when a patient is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the patients record, and the nurse can refer to them before the weaning process begins.

A nurse is working with a client being extubated from the ventilator. Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain?

Baseline arterial blood gas (ABG) levels Explanation: 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. Anemic hypoxia is an issue, but would not be most important factor before weaning ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins.

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 increase of 20 mm Hg from baseline Explanation: 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 teaching a patient how to perform flow type incentive spirometry prior to his scheduled thoracic surgery. What instruction should the nurse provide to the patient?

Breathe in deeply through the spirometer, hold your breath briefly, and then exhale. The patient should be taught to place the mouthpiece of the spirometer firmly in the mouth, breathe air in through the mouth, and hold the breath at the end of inspiration for about 3 seconds. The patient should then exhale slowly through the mouthpiece

The home care nurse is planning to begin breathing retraining exercises with a client newly admitted to the home health service. The home care nurse knows that breathing retraining is especially indicated if the patient has what diagnosis?

COPD Breathing retraining is especially indicated in patients with COPD and dyspnea. Breathing retraining may be indicated in patients with other lung pathologies, but not to the extent indicated in patients with COPD.

Postural drainage has been ordered for a patient who is having difficulty mobilizing her bronchial secretions. Before repositioning the patient and beginning treatment, the nurse should perform what health assessment?

Chest auscultation Chest auscultation should be performed before and after postural drainage in order to evaluate the effectiveness of the therapy. Percussion and palpation are less likely to provide clinically meaningful data for the nurse. PFTs are normally beyond the scope of the nurse and are not necessary immediately before postural drainage.

The nurse is caring for a client following a thoracotomy. Which finding requires immediate intervention by the nurse?

Chest tube drainage, 190 mL/hr Explanation: 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 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 Explanation: Given the vital signs, this client appears to be in shock. Circulatory hypoxia results from inadequate capillary circulation and 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 low blood pressure is consistent with circulatory hypoxia but not consistent with the other options. Anemic hypoxia is a result of decreased effective hemoglobin concentration. Histotoxic hypoxia occurs when a toxic substance interferes with the ability of tissues to use available oxygen. Hypoxemic hypoxia results from a low level of oxygen in the blood.

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 Explanation: 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.

The nurse is preparing to discharge a patient after thoracotomy. The patient is going home on oxygen therapy and requires wound care. As a result, he will receive home care nursing. What should the nurse include in discharge teaching for this patient?

Correct and safe use of oxygen therapy equipment Respiratory care and other treatment modalities (oxygen, incentive spirometry, chest physiotherapy [CPT], and oral, inhaled, or IV medications) may be continued at home. Therefore, the nurse needs to instruct the patient and family in their correct and safe use. The scenario does not indicate the patient needs help with suctioning, postural drainage, or tracheostomy care.

A patient is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching includes what?

Correct use of incentive spirometry Instruction in the use of incentive spirometry begins before surgery to familiarize the patient with its correct use. You do not teach a patient the use of a ventilator; you explain that he may be on a ventilator to help him breathe. Rhythmic breathing and mini-nebulizers are unnecessary.

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 patients respirations. How should the nurse best respond to this assessment finding?

Document that the chest drainage system is operating as it is intended. Feedback: 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.

A patient recovering from thoracic surgery is on long-term mechanical ventilation and becomes very frustrated when he tries to communicate. What intervention should the nurse perform to assist the patient?

Express empathy and then encourage the patient to write, use a picture board, or spell words with an alphabet board. Feedback: If the patient uses an alternative method of communication, he will feel in better control and likely be less frustrated. Assuring the patient that everything will be all right offers false reassurance, and telling him not to be upset minimizes his feelings. Neither of these methods helps the patient to communicate. In a patient with an endotracheal or tracheostomy tube, the family members are also likely to encounter difficulty interpreting the patients wishes. Making them responsible for interpreting the patients gestures may frustrate the family. The patient may be weaned off a mechanical ventilator only when the physiologic parameters for weaning have been met.

The nurse is performing patient education for a patient who is being discharged on mini-nebulizer treatments. What information should the nurse prioritize in the patients discharge teaching?

How to perform diaphragmatic breathing Feedback: Diaphragmatic breathing is a helpful technique to prepare for proper use of the small-volume nebulizer. Patient teaching would not include counting respirations and the patient should not wean herself from treatment without the involvement of her primary care provider. Serial sputum samples are not normally necessary.

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?

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.

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

Hyperbaric Explanation: 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.

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 Explanation: All the nursing diagnoses are appropriate for this client. Per Maslow's hierarchy of needs, airway, breathing, and circulation are the highest priorities within physiological needs. The client has an oxygen saturation of 91%, which is below normal. This places impaired gas exchange as the highest prioritized nursing diagnosis.

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

Intermittent mandatory ventilation (IMV) Explanation: 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 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 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.

A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this patient is necessary. What is the main rationale for this?

Maintaining a patent airway Maintaining a patent (open) airway is achieved through meticulous airway management, whether in an emergency situation such as airway obstruction or in long-term management, as in caring for a patient with an endotracheal or a tracheostomy tube. The other answers are incorrect.

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

Manual resuscitation bag Explanation: The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit at the bedside isn't necessary. Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate the effectiveness of ventilation, this equipment is less important than the manual resuscitation bag.

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?

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

The medical nurse is creating the care plan of an adult patient requiring mechanical ventilation. What nursing action is most appropriate?

Monitor cuff pressure every 8 hours Feedback: The cuff pressure should be monitored every 8 hours. It is important to perform tracheostomy care at least every 8 hours because of the risk of infection. The patient should be encouraged to ambulate, if possible, and a low Fowlers position is not indicated.

A client who is undergoing thoracic surgery has a nursing diagnosis of "Impaired gas exchange related to lung impairment and surgery" on the nursing care plan. Which of the following nursing interventions would be appropriately aligned with this nursing diagnosis? Select all that apply.

Monitor pulmonary status as directed and needed. Regularly assess the client's vital signs every 2 to 4 hours. Encourage deep breathing exercises. Explanation: 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. The nurse would request an order for patient-controlled analgesia if appropriate for the client, but that would be an intervention related to post-surgical pain, not impaired gas exchange. Monitoring and recording hourly intake and output are essential interventions for ensuring appropriate fluid balance but not directly related to impaired gas exchange.

The critical care nurse is precepting a new nurse on the unit. Together they are caring for a patient who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff?

Monitor the pressure in the cuff at least every 8 hours Cuff pressure must be monitored by the respiratory therapist or nurse at least every 8 hours by attaching a handheld pressure gauge to the pilot balloon of the tube or by using the minimal leak volume minimal occlusion volume technique. Plugging is only used when weaning the patient from tracheal support. Deflating the cuff overnight would be unsafe and inappropriate. High cuff pressure can cause tissue trauma.

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 patients needs?

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 patients respiratory status does not require a partial- or nonrebreathing mask.

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 Explanation: 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.

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

Nonrebreathing mask Explanation: The nonrebreathing mask provides high oxygen concentration, but it usually fits poorly. However, if the nonrebreathing mask fits the client snugly and both side exhalation ports have one-way valves, it is possible for the client to receive 100% oxygen, making the nonrebreathing mask a high-flow oxygen system. The Venturi mask provides low levels of supplemental oxygen. The catheter is an inexpensive device that provides a variable fraction of inspired oxygen and may cause gastric distention. A face tent provides a fairly accurate fraction of inspired oxygen but is bulky and uncomfortable. It would not be the device of choice to provide a high oxygen concentration.

A client has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the client complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect?

Oxygen 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, 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) Explanation: The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3-, and PaCO2

The nurse is 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?

Perform shoulder exercises five times daily. Feedback: 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.

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

Pneumonectomy Explanation: 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.

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

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.

A patient has been discharged home after thoracic surgery. The home care nurse performs the initial visit and finds the patient discouraged and saddened. The client states, I am recovering so slowly. I really thought I would be better by now. What nursing action should the nurse prioritize?

Provide emotional support to the patient and family The recovery process may take longer than the patient had expected, and providing support to the patient is an important task for the home care nurse. It is not necessary, based on this scenario, to schedule a visit with the physician within 24 hours, or to get a referral to a psychiatrist or a social worker.

The nurse is caring for a client who is intubated for mechanical ventilation. Which intervention(s) will the nurse implement to reduce the client's risk of injury? Select all that apply.

Provide oral hygiene. Assess for a cuff leak. Reduce pulling on ventilator tubing. Monitor cuff pressure every 8 hours. Position with head above the stomach level. Explanation: Maintaining the endotracheal or tracheostomy tube is an essential part of airway management. Oral hygiene is provided frequently because the oral cavity is a primary source of lung contamination in the client who is intubated. Assessing for a leak from the cuff of the endotracheal tube needs to be done at the same time as providing other respiratory care. Ventilator tubing should be positioned so that there is minimal pulling or distortion of the tube in the trachea which reduces the risk of trauma to the trachea. Cuff pressure is monitored every 8 hours to maintain the pressure at 20 to 25 mm Hg. The head of the bed should be higher than the stomach to reduce the risk of aspiration.

The nurse has admitted a patient who is scheduled for a thoracic resection. The nurse is providing preoperative teaching and is discussing several diagnostic studies that will be required prior to surgery. Which study will be performed to determine whether the planned resection will leave sufficient functioning lung tissue?

Pulmonary function studies Pulmonary function studies are performed to determine whether the planned resection will leave sufficient functioning lung tissue. ABG values are assessed to provide a more complete picture of the functional capacity of the lung. Exercise tolerance tests are useful to determine if the patient who is a candidate for pneumonectomy can tolerate removal of one of the lungs. Preoperative studies, such as a chest x-ray, are performed to provide a baseline for comparison during the postoperative period and to detect any unsuspected abnormalities.

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

Runs of ventricular tachycardia Explanation: Ventricular tachycardia indicates that the client isn't tolerating the weaning process. The weaning process should be stopped before lethal ventricular arrhythmias occur. A respiratory rate of 16 breaths/minute and an oxygen saturation of 93% are normal findings. The client's blood pressure remains stable, so the weaning can continue.

A client seeks medical attention for a new onset of fatigue and changes in coordination. Which additional assessment finding indicates to the nurse that the client is demonstrating signs of low oxygenation? Select all that apply.

Shortness of breath Impaired thought process Agitation Explanation: A change in the client's respiratory rate or pattern may be one of the earliest indicators of the need for oxygen therapy. These changes may result from hypoxemia or hypoxia. Severe hypoxia can be life threatening. The signs and symptoms signaling the need for supplemental oxygen may depend on how suddenly this need develops. The client has new onset of symptoms so the low oxygenation will be associated with acute hypoxia. With acute hypoxia, changes occur in the central nervous system because the neurologic centers are very sensitive to oxygen deprivation. Acute hypoxia that is newly presenting may manifest in signs such as shortness of breath, impaired thought process, and agitation. With long-standing or chronic hypoxia that is not manifesting as a new onset of symptoms, the client may demonstrate apathy, drowsiness, and delayed reaction time. The client may also demonstrate symptoms similar to alcohol intoxication such as impaired judgment. The presence of cough is not a manifestation of acute or chronic hypoxia.

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. Explanation: A high-pressure alarm on a continuous mechanical ventilator indicates an obstruction in the flow of gas from the machine to the client. The nurse should suction the client's artificial airway to remove respiratory secretions that could be causing the obstruction. The sounding of a ventilator alarm has no relationship to the apical pulse. Increasing the oxygen percentage and ventilating with a handheld mechanical ventilator wouldn't correct the airflow blockage.

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. Explanation: 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 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. Explanation: 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 has explained to the patient that after his thoracotomy, it will be important to adhere to a coughing schedule. The patient is concerned about being in too much pain to be able to cough. What would be an appropriate nursing intervention for this client?

Teach him how to perform huffing. The technique of huffing may be helpful for the patient with diminished expiratory flow rates or for the patient who refuses to cough because of severe pain. Huffing is the expulsion of air through an open glottis. Inhalers, nebulizers, and postural drainage are not substitutes for performing coughing exercises.

The nurse caring for a patient with an endotracheal tube recognizes several disadvantages of an endotracheal tube. What would the nurse recognize as a disadvantage of endotracheal tubes?

The cough reflex is depressed. Feedback: There are several disadvantages of an endotracheal tube. Disadvantages include suppression of the patients cough reflex, thickening of secretions, and depressed swallowing reflexes. Ulceration and stricture of the larynx or trachea may develop, but bleeding is not an expected finding. The tube should not influence cognition and daily ABGs are not always required.

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. Explanation: 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.

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. Explanation: 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. Explanation: Endotracheal intubation may be used for no longer than 14 to 21 days, by which time a tracheostomy must be considered to decrease irritation of and trauma to the tracheal lining, to reduce the incidence of vocal cord paralysis (secondary to laryngeal nerve damage), and to decrease the work of breathing (Wiegand, 2011).

While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of the patients closed chest-drainage system. What should the nurse conclude?

The system has an air leak. Feedback: Constant bubbling in the chamber often indicates an air leak and requires immediate assessment and intervention. The patient with a pneumothorax will have intermittent bubbling in the water-seal chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.

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. Explanation: 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 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 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 decrease the work of breathing To reduce stress on the myocardium Explanation: 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.

A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube?

To remove air from the pleural space Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. The primary purpose of a chest tube is not to drain sputum secretions, monitor bleeding, or assist with mechanical ventilation.

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. Explanation: 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 patient with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the physician to order?

Venturi mask The Venturi mask provides the most accurate method of oxygen delivery. Other methods of oxygen delivery include the aerosol mask, tracheostomy collar, and face tents, but these do not match the precision of a Venturi mask.

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

Venturi mask Explanation: The Venturi mask is the most reliable and accurate method for delivering a precise concentration of oxygen through noninvasive means. The mask is constructed in a way that allows a constant flow of room air blended with a fixed flow of oxygen. Nasal cannula, T-piece, and partial-rebreathing masks are not the most reliable and accurate methods of oxygen administration.

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

Volume cycled Explanation: With volume-cycled 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.

The nurse is performing nasotracheal suctioning on a medical patient and obtains copious amounts of secretions from the patients airway, even after inserting and withdrawing the catheter several times. How should the nurse proceed?

Wait several minutes and then repeat suctioning. If additional suctioning is needed, the nurse should withdraw the catheter to the back of the pharynx, reassure the patient, and oxygenate for several minutes before resuming suctioning. Chest physiotherapy and postural drainage are not necessarily indicated.

A patient in the ICU has had an endotracheal tube in place for 3 weeks. The physician has ordered that a tracheostomy tube be placed. The patients family wants to know why the endotracheal tube cannot be left in place. What would be the nurses best response?

When an endotracheal tube is left in too long it can damage the lining of the windpipe. Endotracheal intubation may be used for no longer than 2 to 3 weeks, by which time a tracheostomy must be considered to decrease irritation of and, trauma to, the tracheal lining, to reduce the incidence of vocal cord paralysis (secondary to laryngeal nerve damage), and to decrease the work of breathing. The need for long-term ventilation would not be the primary rationale for this change in treatment. Endotracheal tubes do not diminish the breathing reflex.

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. Explanation: 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 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.

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 Explanation: In general, the nurse should apply suction no longer than 10 seconds. 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.

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. Explanation: 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.

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

synchronized intermittent mandatory ventilation (SIMV). Explanation: 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 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. Explanation: 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.