Chapter 21: Respiratory Care Modalities

What range of pressure within the endotracheal tube cuff does the nurse maintain to prevent both injury and aspiration?

20 to 25 mm Hg Explanation: Usually the pressure is maintained at <25 mm HG (30 cm H2O) water pressure to prevent injury and at >20 mm HG (24 cm H2O) water pressure to prevent aspiration. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis, whereas low cuff pressure can increase the risk of aspiration pneumonia. A water pressure of 10-15 or 15-20 mm Hg would indicate that the cuff is underinflated. A water pressure of 25-30 mm Hg would indicate that the cuff is overinflated.

Which is a correct endotracheal tube cuff pressure?

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

The nurse is assigned to care for a client with a chest tube. The nurse should ensure that which item is kept at the client's bedside?

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

A patient is brought into the emergency department with carbon monoxide poisoning after escaping a house fire. What should the nurse monitor this patient for?

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

The nurse received a client from the post-anesthesia care unit (PACU) who has a chest tube to a closed drainage system. Report from the PACU nurse included drainage in the chest tube at 80 mL of bloody fluid. Fifteen minutes after transfer from the PACU, the chest tube indicates drainage as pictured. The client is reporting pain at "8" on a scale of 0 to 10. The first action of the nurse is to:

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

Which is an adverse reaction that would require the process of weaning from a ventilator to be terminated?

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

The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying?

Circulatory hypoxia Given this patient's vital signs, he appears to be in shock. Circulatory hypoxia is hypoxia resulting from inadequate capillary circulation. It may be caused by decreased cardiac output, local vascular obstruction, low-flow states such as shock, or cardiac arrest. Although tissue partial pressure of oxygen (PO2) is reduced, arterial oxygen (PaO2) remains normal. Circulatory hypoxia is corrected by identifying and treating the underlying cause.

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation?

Endotracheal suctioning Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a coolin

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 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.

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

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

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

Nonrebreathing mask Nonrebreathing masks provide high oxygen concentrations but usually fit poorly. A Venturi mask provides low levels of supplemental oxygen. A catheter is an inexpensive device that provides a variable fraction of inspired oxygen and may cause gastric distention. A face tent provides a fairly accurate fraction of inspired oxygen but is bulky and uncomfortable. It would not be the device of choice to provide a high oxygen concentration.

The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia?

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

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

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

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 client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?

Suction the client's artificial airway. A high-pressure alarm on a continuous mechanical ventilator indicates an obstruction in the flow of 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 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 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 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.

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes?

Water-seal chamber Fluctuations in the water-seal compartment are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respirations. The air-leak meter — not chamber — detects air leaking from the pleural space. The collection chamber connects the chest tube from the client to the system. Drainage from the tube drains into and collects in a series of calibrated columns in this chamber. The suction control ch

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." The nurse should assess the client's pain level before the client does incentive spirometry exercises and administer pain medication as needed. Doing so helps the client take deeper breaths and help prevents atelectasis. The client should breathe in slowly and steadily, and hold his breath for 3 seconds after inhalation. The client should start doing incentive spirometry immediately after surgery and aim to do 10 incentive spirometry breaths every hour.

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

Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved. If the cause of an alarm cannot be determined, the nurse should disconnect the patient from the ventilator and manually ventilate the patient, because leaving the patient on the mechanical ventilator may be dangerous.

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

Oxygen toxicity Oxygen toxicity may occur when too high a concentration of oxygen (greater than 50%) is administered for an extended period (longer than 48 hours) (Urden, Stacy, & Lough, 2014). Signs and symptoms of oxygen toxicity include substernal discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxemia, alveolar atelectasis, and alveolar infiltrates evident on chest x-rays.

A client is 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 (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.

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 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.

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." 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.

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

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

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 <90%, respiratory rate <8 or >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 >60 mm Hg with FiO2 <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.

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

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

A patient with emphysema is placed on continuous oxygen at 2 L/min at home. Why is it important for the nurse to educate the patient and family that they must have No Smoking signs placed on the doors?

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

A client 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.

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

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

After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must:

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