PrepU Respiratory Care Modalities
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? a) The patient is having a stress reaction. b) The patient is hypoxic from suctioning. c) The patient is having a myocardial infarction. d) The patient is in a hypermetabolic state.
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.
The nurse is assessing a patient with chest tubes connected to a drainage system. What should the first action be when the nurse observes excessive bubbling in the water seal chamber? a) Disconnect the system and get another. b) Milk the chest tube. c) Notify the physician. d) Place the head of the patient's bed flat.
Notify the physician. Explanation: Observe for air leaks in the drainage system; they are indicated by constant bubbling in the water seal chamber, or by the air leak indicator in dry systems with a one-way valve. In addition, assess the chest tube system for correctable external leaks. Notify the primary provider immediately of excessive bubbling in the water seal chamber not due to external leaks.
The nurse is preparing to assist the health care provider with the removal of a patient's chest tube. Which of the following instructions will the nurse correctly give the patient? a) "During the removal of the chest tube, do not move because it will make the removal more painful." b) "When the tube is being removed, take a deep breath, exhale, and bear down." c) "Exhale forcefully while the chest tube is being removed." d) "While the chest tube is being removed, raise your arms above your head."
"When the tube is being removed, take a deep breath, exhale, and bear down." Explanation: When assisting in the chest tube's removal, instruct the patient to perform a gentle Valsalva maneuver or to breathe quietly. The chest tube is then clamped and quickly removed. Simultaneously, a small bandage is applied and made airtight with petrolatum gauze covered by a 4 × 4-inch gauze pad and thoroughly covered and sealed with nonporous tape. The other options are incorrect instructions for the patient.
The nurse is preparing to assist the health care provider with the removal of a patient's chest tube. Which of the following instructions will the nurse correctly give the patient? a) "While the chest tube is being removed, raise your arms above your head." b) "During the removal of the chest tube, do not move because it will make the removal more painful." c) "Exhale forcefully while the chest tube is being removed." d) "When the tube is being removed, take a deep breath, exhale, and bear down."
"When the tube is being removed, take a deep breath, exhale, and bear down." Explanation: When assisting in the chest tube's removal, instruct the patient to perform a gentle Valsalva maneuver or to breathe quietly. The chest tube is then clamped and quickly removed. Simultaneously, a small bandage is applied and made airtight with petrolatum gauze covered by a 4 × 4-inch gauze pad and thoroughly covered and sealed with nonporous tape. The other options are incorrect instructions for the patient.
The nurse has instructed a patient on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which of the following? a) Promote the strengthening of the patient's diaphragm b) Promote the patient's ability to intake oxygen c) Promote a more efficient and controlled ventilation and to decrease the work of breathing d) Improve oxygen transport, induce a slow, deep breathing pattern, and assist the patient to control breathing
Improve oxygen transport, induce a slow, deep breathing pattern, and assist the patient to control breathing Explanation: Pursed-lip breathing, which improves oxygen transport, helps induce a slow, deep breathing pattern and assists the patient to control breathing, even during periods of stress. This type of breathing helps prevent airway collapse secondary to loss of lung elasticity in emphysema
A 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? a) An ET cuff leak b) A change in the oxygen concentration without resetting the oxygen level alarm c) Kinking of the ventilator tubing d) A disconnected ventilator tube
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 tube or an ET cuff leak would trigger the low-pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would trigger the oxygen alarm, not the high-pressure alarm.
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? a) An ET cuff leak b) A disconnected ventilator tube c) Kinking of the ventilator tubing d) A change in the oxygen concentration without resetting the oxygen level 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 tube or an ET cuff leak would trigger the low-pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would trigger the oxygen alarm, not the high-pressure alarm.
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: a) Tracheal cuff pressure set at 30 mm Hg b) Symmetry of the client's chest expansion c) A scheduled time for deflation of the tracheal cuff d) Cool air humidified through the tube
Symmetry of the client's chest expansion Explanation: 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 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: a) synchronized intermittent mandatory ventilation (SIMV). b) continuous positive airway pressure (CPAP). c) pressure support ventilation (PSV). d) assist-control (AC) ventilation.
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 client is prescribed postural drainage because secretions are accumulating in the upper lobes of the lungs. The nurse instructs the client to: a) Lay in bed with the head on a pillow. b) Take prescribed albuterol (Ventolin) before performing postural drainage. c) Perform drainage 1 hour after meals. d) Hold each position for 5 minutes.
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 (eg, 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.
Which of the following is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means? a) Partial-rebreathing mask b) T-piece c) Venturi mask d) Nasal cannula
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.
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? a) Air-leak chamber b) Suction control chamber c) Water-seal chamber d) Collection chamber
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.
A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client? a) By placing the call button under the client's pillow b) By providing a tracheostomy plug to use for verbal communication c) By supplying a magic slate or similar device d) By suctioning the client frequently
By supplying a magic slate or similar device Explanation: The nurse should use a nonverbal communication method, such as a magic slate, note pad and pencil, and picture boards (if the client can't write or speak English). The physician orders a tracheostomy plug when a client is being weaned off a tracheostomy; it doesn't enable the client to communicate. The call button, which should be within reach at all times for all clients, can summon attention but doesn't communicate additional information. Suctioning clears the airway but doesn't enable the client to communicate.
A patient with emphysema informs the nurse, "The surgeon will be removing about 30% of my lung so that I will not be so short of breath and will have an improved quality of life." What surgery does the nurse understand the surgeon will perform? a) A wedge resection b) A sleeve resection c) Lobectomy d) A lung volume reduction
A lung volume reduction Explanation: Lung volume reduction is a surgical procedure involving the removal of 20%-30% of a patient's lung through a midsternal incision or video thoracoscopy. The diseased lung tissue is identified on a lung perfusion scan. This surgery leads to significant improvements in dyspnea, exercise capacity, quality of life, and survival of a subgroup of people with end-stage emphysema (Oey, Morgan, Spyt, et al., 2010).
The nurse is caring for a patient with an endotracheal tube (ET). Which of the following nursing interventions is contraindicated? a) Checking the cuff pressure every 6 to 8 hours b) Deflating the cuff routinely c) Deflating the cuff prior to tube removal d) Ensuring that humidified oxygen is always introduced through the tube
Deflating the cuff routinely 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.
After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must: a) encourage coughing and deep breathing. b) clamp the chest tube once every shift. c) report fluctuations in the water-seal chamber. d) milk the chest tube every 2 hours.
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 patient has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the patient complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect? a) Oxygen toxicity b) Oxygen-induced hypoventilation c) Hypoxia d) Oxygen-induced atelectasis
Oxygen toxicity Explanation: Oxygen toxicity may occur when too high a concentration of oxygen (greater than 50%) is administered for an extended period (longer than 48 hours) (Urden, Stacy, & Lough, 2010). Signs and symptoms of oxygen toxicity include substernal discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxemia, alveolar atelectasis, and alveolar infiltrates evident on chest x-rays.
A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? a) The client has a pneumothorax. b) The system has an air leak. c) The system is functioning normally. d) The chest tube is obstructed.
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.
Which type of ventilator has a pre-sent volume of air to be delivered with each inspiration? a) Pressure cycled b) Volume cycled c) Time cycled d) Negative pressure
Volume cycled Explanation: With volume-cycled ventilation, the volume of air to be delivered with each inspiration is present. Negative pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a present pressure, and then cycles off, and expiration occurs passively.
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? a) Collection chamber b) Suction control chamber c) Air-leak chamber d) Water-seal chamber
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
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. a) To provide visual feedback to encourage the client to inhale slowly and deeply b) To decrease the work of breathing c) To clear respiratory secretions d) To reduce stress on the myocardium e) To provide adequate transport of oxygen in the blood
• 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.
Which of the following is a potential complication of a low pressure in the ET cuff? a) Tracheal bleeding b) Tracheal ischemia c) Aspiration pneumonia d) Pressure necrosis
Aspiration pneumonia Explanation: Low pressure in the cuff can increase the risk for aspiration pneumonia. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis.
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? a) Auscultate the lung for adventitious sounds. b) Have the patient cough. c) Assess the CO2 level to determine if the patient requires suctioning. d) Have the patient inform the nurse of the need 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.
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? a) Check for an apical pulse. b) Ventilate the client with a handheld mechanical ventilator. c) Increase the oxygen percentage. d) Suction the client's artificial airway.
Suction the client's artificial airway. Explanation: A high-pressure alarm on a continuous mechanical ventilator indicates an obstruction in the flow of oxygen from the machine to the client. The nurse should suction the client's artificial airway to remove respiratory secretions that could be causing the obstruction. The sounding of a ventilator alarm has no relationship to the apical pulse. Increasing the oxygen percentage and ventilating with a handheld mechanical ventilator wouldn't correct the airflow blockage.
Which type of ventilator has a present volume of air to be delivered with each inspiration? a) Time-cycled b) Negative-pressure c) Volume-controlled d) Pressure-cycled
Volume-controlled Explanation: With volume-controlled ventilation, the volume of air to be delivered with each inspiration is present. Negative pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a present pressure, and then cycles off, and expiration occurs passively.
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: a) take a deep breath as the nurse deflates the cuff. b) hold the breath as the cuff is being reinflated. c) cough as the cuff is being deflated. d) exhale deeply as the nurse reinflates the cuff.
cough as the cuff is being deflated. Explanation: The nurse should instruct the client to cough during cuff deflation. If the client can't cough, the nurse should perform suctioning to prevent aspiration of secretions. Because the cuff should be deflated during expiration, the client shouldn't take a deep breath as the nurse deflates the cuff. Likewise, because the cuff is reinflated during inspiration, the client shouldn't hold the breath or exhale deeply during reinflation.
A 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: a) keeping the tracheostomy tube plugged. b) using the minimal-leak technique with cuff pressure less than 25 cm H2O. c) using a cuffed tracheostomy tube. d) suctioning the tracheostomy tube frequently.
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
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. a) Monitor and record hourly intake and output. b) Monitor pulmonary status as directed and needed. c) Regularly assess the client's vital signs every 2 to 4 hours. d) Encourage deep breathing exercises. e) Maintain an open airway.
• 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. 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 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: a) Notify the physician. b) Lay the client's head to a flat position. c) Assess pulse and blood pressure. d) Administer prescribed pain medication.
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 nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs? a) Inspection b) Chest X-ray c) Auscultation d) Arterial blood gas (ABG) levels
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 nurse is caring for a patient with an endotracheal tube (ET). Which of the following nursing interventions is contraindicated? a) Checking the cuff pressure every 6 to 8 hours b) Ensuring that humidified oxygen is always introduced through the tube c) Deflating the cuff prior to tube removal d) Deflating the cuff routinely
Deflating the cuff routinely Explanation: Routine cuff deflation is not recommended because of the increased risk for aspiration and hypoxia. The cuff is deflated before the ET is removed. Cuff pressures should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tube.
A client with 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? a) Manual resuscitation bag b) Water-seal chest drainage set-up c) Oxygen analyzer d) Tracheostomy cleaning kit
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 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. a) To clear respiratory secretions b) To reduce stress on the myocardium c) To provide adequate transport of oxygen in the blood d) To decrease the work of breathing e) To provide visual feedback to encourage the client to inhale slowly and deeply
• 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.
